Adding ultrasound to treat-to-target shows no benefit in achieving clinical remission nor in slowing radiographic progression in rheumatoid arthritis: results from a multicenter prospective cohort

OBJECTIVE

To assess whether using ultrasound (US) in addition to clinical information versus only clinical information in a treat-to-target (T2T) strategy leads to more clinical remission and to less radiographic progression in RA.

METHODS

Patients with RA from the 2-year prospective BIODAM cohort were included. Clinical and US data (US7-score) were collected every 3 months and hands and feet radiographs every 6 months. At each visit, it was decided whether patients were treated according to the clinical definition of T2T with DAS44 remission as benchmark (T2T-DAS44). T2T-DAS44 was correctly applied if: (i) DAS44 remission had been achieved or (ii) if not, treatment was intensified. A T2T strategy also considering US data (T2T-DAS44-US) was correctly applied if: (i) both DAS44 and US remission (synovitis-score < 2, Doppler-score = 0) were present; or (ii) if not, treatment was intensified. The effect of T2T-DAS44-US on attaining clinical remission and on change in Sharp-van der Heijde score compared to T2T-DAS44 was analysed.

RESULTS

A total of 1016 visits of 128 patients were included. T2T-DAS44 was correctly followed in 24% of visits and T2T-DAS44-US in 41%. DAS44 < 1.6 was achieved in 39% of visits. Compared to T2T-DAS44, using the T2T-DAS44-US strategy resulted in a 41% lower likelihood of DAS44 remission [OR (95% CI): 0.59 (0.40;0.87)] and had no effect on radiographic progression [β(95% CI): 0.11 (- 0.16;0.39)] assessed at various intervals up to 12 months later.

CONCLUSION

Our results do not suggest a benefit of using the US7-score in addition to clinical information as a T2T benchmark compared to clinical information alone. Key Points • Ultrasound has a valuable role in diagnostic evaluation of rheumatoid arthritis, but it is unclear whether adding ultrasound to the clinical assessment in a treat-to-target (T2T) strategy leads to more patients achieving remission and reduction in radiographic progression. • Our data from a real-world study demonstrated that adding information from ultrasound to the clinical assessment in a T2T strategy led to a lower rather than a higher likelihood of obtaining clinical remission as compared to using only clinical assessment. • Our data demonstrated that adding ultrasound data to a T2T strategy based only on clinical assessment did not offer additional protection against radiographic progression in patients with RA. • Adding US to a T2T strategy based on clinical assessment led to far more treatment intensifications (with consequences for costs and exposure to adverse events) without yielding a meaningful clinical benefit.

The OMERACT whole-body MRI scoring system for inflammation in peripheral joints and entheses (WIPE) in spondyloarthritis - reference image atlas for the knee region

OBJECTIVE

To develop a reference image atlas for the Outcome Measures in Rheumatology whole-body MRI scoring system for inflammation in peripheral joints and entheses (OMERACT MRI-WIPE) of the knee region.

METHODS

Image examples of each pathology, location and grade, were collected and discussed at web-based, interactive meetings within the OMERACT MRI in Arthritis Working Group. Subsequently, reference images were selected by consensus.

RESULTS

Reference images for each grade, pathology and location are depicted, along with definitions, reader rules and recommended MRI-sequences.

CONCLUSION

The atlas guides scoring whole-body MRIs for inflammation in joints and entheses of the knee region according to MRI-WIPE methodology in clinical trials and cohorts.

Hip and pelvis region MRI reference image atlas for scoring inflammation in peripheral joints and entheses according to the OMERACT-MRI WIPE scoring system in patients with spondyloarthritis

OBJECTIVE

To develop a reference image atlas for scoring the hip/pelvis region according to the OMERACT whole-body MRI scoring system for inflammation in peripheral joints and entheses (MRI-WIPE).

METHODS

We collected image examples of each pathology, location and grade, discussed them at web-based, interactive meetings and, finally, selected reference images by consensus.

RESULTS

Reference images for each grade and location of osteitis, synovitis and soft tissue inflammation are provided, as are definitions, reader rules and recommended MRI-sequences.

CONCLUSION

A reference image atlas was created to guide scoring whole-body MRIs for arthritis and enthesitis in the hip/pelvis region in spondyloarthritis/psoriatic arthritis clinical trials and cohorts.

Validation of SPARCC MRI-RETIC e-tools for increasing scoring proficiency of MRI sacroiliac joint lesions in axial spondyloarthritis

BACKGROUND

The Spondyloarthritis Research Consortium of Canada (SPARCC) developers have created web-based calibration modules for the SPARCC MRI sacroiliac joint (SIJ) scoring methods. We aimed to test the impact of applying these e-modules on the feasibility and reliability of these methods.

METHODS

The SPARCC-SIJ RETIC e-modules contain cases with baseline and follow-up scans and an online scoring interface. Visual real-time feedback regarding concordance/discordance of scoring with expert readers is provided by a colour-coding scheme. Reliability is assessed in real time by intraclass correlation coefficient (ICC), cases being scored until ICC targets are attained. Participating readers (n=17) from the EuroSpA Imaging project were randomised to one of two reader calibration strategies that each comprised three stages. Baseline and follow-up scans from 25 cases were scored after each stage was completed. Reliability was compared with a SPARCC developer, and the System Usability Scale (SUS) assessed feasibility.

RESULTS

The reliability of readers for scoring bone marrow oedema was high after the first stage of calibration, and only minor improvement was noted following the use of the inflammation module. Greater enhancement of reader reliability was evident after the use of the structural module and was most consistently evident for the scoring of erosion (ICC status/change: stage 1 (0.42/0.20) to stage 3 (0.50/0.38)) and backfill (ICC status/change: stage 1 (0.51/0.19) to stage 3 (0.69/0.41)). The feasibility of both e-modules was evident by high SUS scores.

CONCLUSION

The SPARCC-SIJ RETIC e-modules are feasible, effective knowledge transfer tools, and their use is recommended before using the SPARCC methods for clinical research and tria.

Systematic calibration reduces sources of variability for the preliminary OMERACT juvenile idiopathic arthritis MRI- sacroiliac joint score (OMERACT JAMRIS-SIJ)

OBJECTIVE

To determine whether systematic calibration enhances scoring proficiency of the OMERACT juvenile idiopathic arthritis MRI-Sacroiliac Joint score (JAMRIS-SIJ) and whether contrast-enhancement enhances its performance.

METHODS

MRI SIJ scans of 50 cases with juvenile spondyloarthritis were scored by 7 raters after calibration with 3 different knowledge transfer tools.

RESULTS

Calibrated readers achieved greater reliability for scoring certain inflammatory and structural lesions. Sensitivity and reliability for scoring inflammatory lesions was greater on fluid-sensitive compared to contrast-enhanced sequences.

CONCLUSION

Systematic calibration should be implemented prior to the use of JAMRIS-SIJ for clinical trials. It is unlikely that contrast-enhanced MRI will improve the performance of this method.

Stricter treat-to-target in RA does not result in less radiographic progression: a longitudinal analysis in RA BIODAM

OBJECTIVES

To investigate whether meticulously following a treat-to-target (T2T)-strategy in daily clinical practice will lead to less radiographic progression in patients with active RA who start (new) DMARD-therapy.

METHODS

Patients with RA from 10 countries starting/changing conventional synthetic or biologic DMARDs because of active RA, and in whom treatment intensification according to the T2T principle was pursued, were assessed for disease activity every 3 months for 2 years (RA-BIODAM cohort). The primary outcome was the change in Sharp-van der Heijde (SvdH) score, assessed every 6 months. Per 3-month interval DAS44-T2T could be followed zero, one or two times (in a total of two visits). The relation between T2T intensity and change in SvdH-score was modelled by generalized estimating equations.

RESULTS

In total, 511 patients were included [mean (s.d.) age: 56 (13) years; 76% female]. Mean 2-year SvdH progression was 2.2 (4.1) units (median: 1 unit). A stricter application of T2T in a 3-month interval did not reduce progression in the same 6-month interval [parameter estimates (for yes vs no): +0.15 units (95% CI: -0.04, 0.33) for 2 vs 0 visits; and +0.08 units (-0.06; 0.22) for 1 vs 0 visits] nor did it reduce progression in the subsequent 6-month interval.

CONCLUSIONS

In this daily practice cohort, following T2T principles more meticulously did not result in less radiographic progression than a somewhat more lenient attitude towards T2T. One possible interpretation of these results is that the intention to apply T2T already suffices and that a more stringent approach does not further improve outcome.

POS0995 VALIDATION OF THE SPARCC MRI-RETIC E-TOOL FOR INCREASING SCORING PROFICIENCY OF MRI LESIONS IN AXIAL SPONDYLOARTHRITIS

Background

The web-based Spondyloarthritis Research Consortium of Canada (SPARCC) real-time iterative calibration (RETIC) modules for scoring MRI lesions in axial spondyloarthritis (axSpA) have been created by SPARCC developers to enable remote training of readers to appropriately use the SPARCC MRI inflammation and structural damage instruments and to attain adequate scoring proficiency.

Objectives

We aimed to test the performance of these modules in enhancing scoring proficiency in comparison to SPARCC developers.

Methods

The SPARCCRETIC SIJ inflammation and structural damage modules are each comprised of 50 DICOM axSpA cases with baseline and follow up scans and an online scoring interface based on SIJ quadrants. Continuous visual real-time feedback regarding concordance/discordance of scoring per SIJ quadrant with expert readers is provided by a color-coding scheme. Reliability is assessed in real-time by intra-class correlation coefficient (ICC), ICC data being provided every 10 cases, which are scored until proficiency targets for ICC are attained. In the present exercise, participants (n=15) from the EuroSpA Imaging project were randomized, stratified by reader expertise in scoring with SPARCC, to one of two reader training strategies (groups A and B) that each comprised 3 stages (25 patients per stage, 2 timepoints, blinded to chronology; independent assessment of Inflammatory and structural lesions): Group A. 1. Review of original SPARCC manuscript describing scoring method. 2. Review of PowerPoint summary of SPARCC method plus completion of SPARCCRETIC module. 3. Re-review of PowerPoint summary. Group B. Same 3-step strategy as A except SPARCCRETIC module completed at stage 3. The reliability of scoring was compared to an expert radiologist (SPARCC developer).

Results

Very good scoring proficiency for status and change scores was evident for SPARCC BME even by non-experienced readers with similar levels of reliability irrespective of prior expertise. The beneficial impact of the SPARCCRETIC module on scoring proficiency was most consistently evident for the scoring of structural lesions and for Strategy B, where the impact was evident for all structural lesions, level of reader expertise, and status as well as change scores (Table 1). Scoring proficiency improved the most for the least experienced readers (Figure 1).

Table 1.

Inter-rater reliability (Status/Change ICC) compared to radiologist SPARCC developer

MRI LesionReader expertiseStrategy AStrategy BStage 1 cases (n=25)Stage 2 cases (n=25)Stage 3 cases (n=25)Stage 1 cases (n=25)Stage 2 cases (n=25)Stage 3 cases (n=25)BMENone (n=4)0.91 / 0.940.83/0.820.77/0.780.82/0.880.65/0.820.88/0.90Intermediate (n=6)0.88/0.880.90/0.900.85/0.900.93/0.940.78/0.800.83/0.80Experienced (n=5)0.92/0.940.90/0.880.92/0.930.83/0.880.84/0.900.89/0.89ANKYLOSISNone (n=4)0.86/0.660.83/0.280.86/0.780.66/0.410.69/0.340.88/0.80Intermediate (n=6)0.89/0.570.83/0.370.92/0.810.82/0.680.74/0.470.93/0.84Experienced (n=5)0.96/0.760.93/0.640.94/0.860.97/0.240.83/0.410.91/0.79BACKFILLNone (n=4)-0.08/-0.050.38/0.220.59/0.380.64/0.130.05/-0.090.47/0.27Intermediate (n=6)0.41/0.130.44/0.420.69/0.390.50/0.220.30/0.300.70/0.42Experienced (n=5)0.82/0.380.55/0.400.91/0.640.65/0.240.21/0.260.71/0.30EROSIONNone (n=4)0.13/-0.080.67/0.420.51/0.330.34/0.330.23/0.080.38/0.37Intermediate (n=6)0.42/0.180.56/0.120.51/0.440.33/0.270.45/0.180.53/0.39Experienced (n=5)0.61/0.330.64/0.340.64/0.420.51/0.270.58/0.110.62/0.31FAT METAPLASIANone (n=4)0.62/0.540.30/0.170.57/0.290.43/0.530.38/0.070.83/0.63Intermediate (n=6)0.49/0.380.59/0.300.79/0.510.57/0.780.50/0.420.81/0.47Experienced (n=5)0.75/0.620.81/0.340.91/0.700.84/0.900.56/0.130.78/0.37

Conclusion

Attaining scoring proficiency for MRI structural lesions in axSpA is difficult but can be consistently improved by using the SPARCCRETIC module, even for experienced readers.

Figure 1.

Disclosure of Interests

Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Boehringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer, UCB, Anna Enevold Fløistrup Hadsbjerg Grant/research support from: Novartis, Mikkel Østergaard Consultant of: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli Lilly and Company, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, UCB, Grant/research support from: AbbVie, BMS, Merck, Celgene, Novartis, Raphael Micheroli: None declared, Susanne Juhl Pedersen Grant/research support from: Novartis, Adrian Ciurea: None declared, Nora Vladimirova Grant/research support from: Novartis, Michael J Nissen Speakers bureau: Eli-Lilly, Janssen, Novartis, Consultant of: Abbvie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, Kristyna Bubova: None declared, Stephanie Wichuk: None declared, Manouk de Hooge: None declared, Ashish Jacob Mathew Grant/research support from: Novartis, Karlo Pintaric: None declared, Monika Gregová: None declared, Ziga Snoj: None declared, Marie Wetterslev: None declared, Karel Gorican: None declared, Joel Paschke: None declared, Iris Eshed: None declared, Robert G Lambert Paid instructor for: Novartis

POS0111 MORE METICULOUSLY FOLLOWING TREAT-TO-TARGET IN RA DOES NOT LEAD TO LESS RADIOGRAPHIC PROGRESSION: A LONGITUDINAL ANALYSIS IN BIODAM

Background

A Treat-to-Target approach (T2T) is broadly considered to lead to better clinical outcomes and recommended in patients with RA. However, very few studies have analyzed the effect of T2T on radiographic progression, and any such studies have provided inconsistent results.

Objectives

To investigate whether meticulously following a treat-to-target (T2T)-strategy in daily clinical practice leads to lower radiographic progression in RA.

Methods

Patients from the multicenter RA-BIODAM cohort with ≥2 consecutive visits with radiographs available were included. In RA-BIODAM patients were enrolled as they were initiating a new csDMARD/bDMARD treatment were followed-up with the intention to benchmark and intensify treatment. The primary outcome of this analysis was the change in Sharp-van der Heijde score (SvdH, 0-448), assessed every 6 months, using average scores from 2 readers (scores with known chronological order). Following a DAS44-T2T remission strategy, which was defined at each 3-month visit, was the main variable of interest. Patients were categorized based on the proportion of visits in which T2T was followed according to our definition: very low (≤40% of the visits, low (>40%, <62.5%), high (≥62.5%, ≤75%) and very high (>75%). Radiographic progression at 2 years was visualized across groups by cumulative probability plots. Per 3-month interval T2T could be followed zero, one or two times (in a total of 2 visits). Associations between the number of visits with T2T in an interval and radiographic progression, both in the same and in the subsequent 6-month interval, were analysed by generalised estimating equations, adjusted for age, gender, disease duration and country.

Results

In total, 511 patients were included (mean (SD) age: 56 (13) years; 76% female). After 2 years, patients showed on average 2.2 (4.1) units progression (median:1 unit). Mean (SD) 2-year progression was not significantly different across categories of T2T: very low: 2.1 (2.7)-units; low: 2.8 (6.0); high: 2.4 (4.5), very high: 1.6 (2.2) (Figure 1). Meticulously following-up T2T in a 3-month interval neither reduced progression in the same 6-month interval (parameter estimates (for yes vs no): +0.15 units (95%CI: -0.04 to 0.33) for 2 vs 0 visits; and +0.08 units (-0.06;0.22) for 1 vs 0 visits) nor did it reduce progression in the subsequent 6-month interval (Table 1).

Table 1.

Effect of following DAS44-remission-T2T strategy on 6-month radiographic progression over 2 years

Change in radiographic damage(regression coefficient (95% CI))N=506T2T during 3 months on radiographic progression in the same 6-month period 2 visits vs 0 followed0.15 (-0.04; 0.33) 1 visit vs 0 followed0.08 (-0.06; 0.22)T2T during 3 months on radiographic progression in the subsequent 6-month period 2 visits vs 0 followed-0.09 (-0.28; 0.10) 1 visit vs 0 followed-0.10 (-0.24; 0.05)Figure 1.

Cumulative probability plot with 2-year radiographic progression according to the proportion of 3-monthly visits with T2T followed

Conclusion

In this daily practice cohort, more meticulously following T2T principles did not result in more reduction of radiographic progression than a somewhat more liberal attitude toward T2T. One possible interpretation of these results is that the intention to apply T2T already suffices and that a more stringent approach does not further improve outcome.

Acknowledgements

BIODAM was financially supported by an unrestricted grant from AbbVie

Disclosure of Interests

Sofia Ramiro Speakers bureau: Eli Lilly, MSD, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, MSD, Novartis, Pfizer, UCB, Sanofi, Grant/research support from: AbbVie, Galapagos, Novartis, Pfizer, UCB, Robert B.M. Landewé Speakers bureau: AbbVie, BMS, Gilead, Galapagos, GSK,Janssen, Lilly, Novartis, Pfizer, UCB, Consultant of: AbbVie, BMS, Gilead, Galapagos, GSK,Janssen, Lilly, Novartis, Pfizer, UCB

Dr Landewé owns Rheumatology Consultancy BV, Désirée van der Heijde Consultant of: AbbVie, Bayer, BMS, Cyxone, Eisai, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Lilly, Novartis, Pfizer, UCB Pharma. Director of Imaging Rheumatology bv., Alexandre Sepriano Speakers bureau: Novartis, Consultant of: UCB, Oliver FitzGerald Speakers bureau: Biogen, Novartis, AbbVie, BMS, Pfizer, Grant/research support from: BMS, Novartis, UCB, Pfizer, Lilly, Janssen, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Merck, Novartis, Orion, Pfizer, Roche and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, Amgen, BMS, Merck, Celgene and Novartis, Joanne Homik: None declared, Ori Elkayam Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, BI, Janssen, Consultant of: Pfizer, Lilly, Novartis, Abbvie, BI, Janssen, Grant/research support from: Pfizer, Abbvie, Janssen, Carter Thorne Consultant of: Abbvie, Organon, Pfizer, Sandoz, Maggie Larché Speakers bureau: AbbVie, Actelion, Amgen, BMS, Boehringer-Ingelheim, Fresenius-Kabi, Gilead, Janssen, Mallinckrodt, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi, Sobi, UCB, Grant/research support from: Abbvie, BMS, Gianfranco Ferraccioli Speakers bureau: SOBI, Consultant of: Abbivie, Marina Backhaus: None declared, Gilles Boire Speakers bureau: Abbvie Canada, BMS Canada, Lilly Canada, Janssen Canada, Merck Canada, Pfizer Canada, Viatris, Consultant of: Abbvie Canada, Amgen Canada, BMS Canada, Celgene, GileadSciences, Janssen Canada, Lilly Canada, Merck Canada, Mylan Canada, Novartis Canada, Pfizer Canada, Roche Canada, Samsung Bioepis, Sanofi Canada, Teva, Grant/research support from: Lilly Canada, BMS Canada, Pfizer, Sandoz Canada, UCB Canada, Merck Canada, Novartis Canada, Roche Canada, Bernard Combe Speakers bureau: Abbvie, BMS,Celltrion,Galapgos-Gilead, Janssen, Lilly, MERCK, Pfizer,Roche-Chugai, Consultant of: Abbvie, Celltrion,Galapgos-Gilead, Janssen, Lilly, MERCK, Roche-Chugai, Grant/research support from: Pfizer, Roche-chugai, Thierry Schaeverbeke: None declared, Alain Saraux Speakers bureau: Abbvie, Lilly, Nordic, Novartis, Pfizer, Roche-Chugai, Sanofi, UCB, Consultant of: Abbvie, Lilly, Nordic, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Novartis, Fresenius, Lilly, Maxime Dougados Consultant of: Pfizer, AbbVie, UCB, Merck, Lilly, Novartis, BMS, Galapagos, Biogen, Roche, Grant/research support from: Pfizer, AbbVie, UCB, Merck, Lilly, Novartis, BMS, Galapagos, Biogen, Roche, Maurizio Rossini Speakers bureau: Amgen, Abbvie, BMS, Eli-Lilly, Galapagos,MSD, Novartis, Pfizer, Sandoz, Theramex, UCB, Marcello Govoni Speakers bureau: Abbvie, Pfizer, Galapagos, BMS, Eli-Lilly, Paid instructor for: Pfizer, Consultant of: Abbvie, BMS, Novartis, Astrazeneca, Pfizer, Luigi Sinigaglia: None declared, Alain Cantagrel Speakers bureau: Abbvie, Amgen, Biogen, BMS, Janssen, Lilly France, Médac, MSD France, Nordic-Pharma, Novartis, Pfizer, Sanofi Aventis, UCB, Consultant of: BMS, Janssen, Lilly France, MSD France, Sandoz, Grant/research support from: MSD France, Novartis, Pfizer, Cornelia Allaart: None declared, Cheryl Barnabe Speakers bureau: Sanofi Genzyme, Pfizer, Fresenius Kabi, Janssen, Consultant of: Gilead, Celltrion Healthcare, Clifton Bingham Consultant of: AbbVie, BMS, Eli Lilly, Janssen, Moderna, Pfizer, Sanofi, Grant/research support from: BMS, Dirkjan van Schaardenburg: None declared, Hilde Berner Hammer Speakers bureau: AbbVie, Novartis, Lilly, Rana Dadashova: None declared, Edna Hutchings: None declared, Joel Paschke: None declared, Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Boehringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer

Magnetic resonance imaging findings in the normal pediatric sacroiliac joint space that can simulate disease

BACKGROUND

Magnetic resonance imaging (MRI) features of active sacroiliac joint inflammation include joint space fluid and enhancement, but it is unclear to what extent these are present in normal children.

OBJECTIVE

To describe normal MRI appearances of pediatric sacroiliac joint spaces in boys and girls of varying ages.

MATERIALS AND METHODS

In this ethics-approved prospective study, 251 children (119 boys, 132 girls; mean age: 12.4 years, range: 6.1-18.0 years), had both oblique-coronal T1-weighted and short tau inversion recovery (STIR) sacroiliac joint MRI. Of these, 127 were imaged for other reasons and had asymptomatic sacroiliac joints ("normal cohort") while 124 had low back pain with no features of sacroiliitis on initial clinical MRI review ("low-back-pain cohort"). Post-gadolinium T1-weighted sequences were available in 16/127 normal and 124/124 low-back-pain subjects. Three experienced radiologists scored high signal in the sacroiliac joint space on STIR (score 0=absent; 1=high signal compared to normal bone marrow present anywhere in the joint but not as bright as fluid [compared to vessels, cerebrospinal fluid]; 2=definite fluid signal in part of the joint; 3=definite fluid signal, entire vertical height, majority of slices) and, when available, joint space post-contrast enhancement (0=no high signal/enhancement; 1=thin, symmetrical, mildly increased linear high signal present in the joint space; 2=focal, thick or intense enhancement). Associations between joint signal scores, age, gender and sacral apophyseal closure were analysed.

RESULTS

Increased signal on STIR (score 1-3) was present in 74.7% of pediatric sacroiliac joint spaces, as intense as fluid in 18.4%. There was no significant difference in proportion by gender, side or cohort, but girls showed peak signal earlier than boys (10 years old vs. 12 years old, respectively). On post-gadolinium T1-weighted sequences, a thin rim of increased signal was nearly universally seen in sacroiliac joint spaces without focal, intense or thick post-contrast enhancement.

CONCLUSION

Sacroiliac joint spaces of most children demonstrate mildly increased signal on STIR, compared to normal bone marrow, and thin rim-like enhancement on post-contrast T1 images, likely related to cartilage. These findings should not be confused with sacroiliitis.

Joint and entheseal inflammation in the knee region in spondyloarthritis - reliability and responsiveness of two OMERACT whole-body MRI scores

OBJECTIVE

To perform region-based development of whole-body MRI through validation of knee region scoring systems in spondyloarthritis (SpA).

METHODS

Assessment of knee inflammatory pathologies using 2 systems, OMERACT MRI Whole-body score for Inflammation in Peripheral joints and Entheses (MRI-WIPE) and Knee Inflammation MRI Scoring System (KIMRISS), in 4 iterative multi-reader exercises.

RESULTS

In the final exercise, reliability was mostly good for readers with highest agreement in previous exercise. Median pairwise single-measure ICCs for osteitis and synovitis/effusion status/change were 0.71/0.48 (WIPE-osteitis), 0.48/0.77 (WIPE-synovitis/effusion), 0.59/0.91 (KIMRISS-osteitis) and 0.92/0.97 (KIMRISS-synovitis/effusion). SRMs were 0.74 (WIPE-synovitis/effusion) and 0.78 (KIMRISS-synovitis/effusion).

CONCLUSION

MRI-WIPE and KIMRISS may both be useful in SpA whole-body evaluation studies.

The OMERACT Knee Inflammation MRI Scoring System: Validation of quantitative methodologies and tri-compartmental overlays in osteoarthritis

OBJECTIVE

To validate a revised version of the KIMRISS method for quantification of BML and synovitis-effusion in the knee by comparison with an established method, MOAKS.

METHODS

Novel calibration tools were developed for both methods. We compared reliability for status and change scores of BML and synovitis-effusion on baseline and one-year MRI scans.

RESULTS

Significant increase in both BML and synovitis-effusion was evident using KIMRISS but only for synovitis-effusion using MOAKS. Pre-specified targets for acceptable reliability (≥0.80 and ≥0.70 for status and change scores, respectively) were achieved more frequently for KIMRISS for both BML and synovitis.

CONCLUSION

Per OFISA criteria, KIMRISS should progress to assessment of discrimination.

POS1101 THE OMERACT KNEE INFLAMMATION MRI SCORING SYSTEM: VALIDATION OF QUANTITATIVE METHODOLOGIES AND TRI-COMPARTMENTAL OVERLAYS BY COMPARISON WITH THE MRI OSTEOARTHRITIS KNEE SCORE

Background:

Randomized controlled trials have targeted reducing the size of BML and degree of synovitis for the treatment of OA. We have developed the OMERACT Knee Inflammation MRI Scoring System (KIMRISS) and have recently refined it to maximize reliability and sensitivity to change. Innovations include electronic overlays for assessment of BML in 500 subregions, a web-based interface with direct online scoring, and real-time iterative calibration (RETIC) prior to reading exercises. Synovitis-effusion (S-E) is also scored on all consecutive sagittal slices on a web-based interface.

Objectives:

We aimed to test the feasibility, reliability, and responsiveness of KIMRISS versus an established method, MOAKS, in two multi-reader exercises.

Methods:

KIMRISS incorporates web-based graphic overlays for each of femur, tibia, and patella (range 0-500). S-E is recorded as the largest diameter perpendicular to the longest axis of this feature (range 0-100). All scores are pro-rated for a standardized number of MRI slices. In a pre-reading exercise for KIMRISS, readers scored sufficient cases in RETIC to attain scoring proficiency, pre-specified as an ICC of ≥0.80 and ≥0.70 for status and change scores of BML and S-E compared to developer reads. A new web-based scoring platform with overlays designating different subregions for scoring BML was developed for MOAKS. We compared reliability for status and change scores of BML and S-E in 2 international multi-reader exercises of baseline and one-year MRI scans from the Osteoarthritis Initiative: A. 4 expert readers and an OMERACT fellow scored 38 cases selected for MOAKS BML score ≥1. B. 7 expert readers and an OMERACT fellow scored 60 cases selected for MOAKS BML ≥3 and Kellgren-Lawrence (K-L) grade <3. Reliability was assessed by intra-class correlation coefficient (ICC) and Smallest Detectable Change (SDC), responsiveness by the standardized response mean (SRM), and feasibility using the System Usability Scale (SUS scoring range 0-100).

Results:

For exercises A/B, subjects were 55.3%/ 26.7% male, mean(±SD) age 61.7(±9.1)/61.9(8.8) years, and radiographic K-L grade ≤2 in 39.4%/100%. Change was small in both exercises (<5% of scoring range for KIMRISS and MOAKS BML and S-E) with comparable responsiveness (Table 1). Despite this, ICC for change was consistently good to very good for both BML and S-E and consistently better for KIMRISS (Table 1). Mean SUS scores were 88.2 for KIMRISS and 54.3 for MOAKS.

Table 1.

KIMRISS and MOAKS scores in Two International Multi-reader Exercises

MethodMRI featureScores mean (SD)SDC(% of max)P valueSRMBaselineOne-year Follow upChangeEXERCISE AMOAKSBML3.6 (2.9)3.4 (2.3)-0.2 (1.9)1.0 (2.2%)0.72-0.11Synovitis-effusion1.3 (0.8)1.5 (0.8)0.2 (0.4)0.4 (13.3%)0.0170.5KIMRISSBML15.7 (13.3)21.2 (22.5)5.5 (15.3)5.6 (1.1%)0.0220.36Synovitis-effusion21.8 (12.0)24.3 (11.9)2.5 (7.4)2.8 (2.8%)0.0430.34EXERCISE BMOAKSBML4.2 (2.6)3.7 (2.4)-0.5 (2.1)1.1 (2.4%)0.083-0.24Synovitis-effusion1.2 (0.7)1.3 (0.8)0.0 (0.5)0.4 (13.3%)0.590.0KIMRISSBML18.0 (17.5)15.9 (14.3)-2.1 (12.3)5.9 (1.2%)0.19-0.17Synovitis-effusion21.8 (9.3)22.9 (10.8)1.1 (7.1)2.2 (2.2%)0.250.15Intra-class Correlation Coefficients (95%CI)MethodMRI featureExercise AExercise BKIMRISS statusKIMRISS changeBML0.86 (0.78-0.92)0.88 (0.81-0.93)0.80 (0.70-0.87)0.72 (0.64-0.80)MOAKS statusMOAKS changeBML0.71 (0.46-0.85)0.76 (0.64-0.85)0.67 (0.56-0.77)0.69 (0.60-0.78)KIMRISS statusKIMRISS changeSynovitis-effusion0.88 (0.81-0.93)0.87 (0.79-0.92)0.75 (0.52-0.86)0.87 (0.82-0.91)MOAKS statusMOAKS changeSynovitis-effusion0.66 (0.4-0.79)0.52 (0.36-0.67)0.65 (0.52-0.75)0.48 (0.37-0.60)

Conclusion:

The KIMRISS method for scoring BML and Synovitis-Effusion scores highly for feasibility and demonstrates consistently high reliability when compared to MOAKS. Further validation for responsiveness is necessary in cases with greater change in MRI features than in the OAI dataset.

Disclosure of Interests:

None declared.

POS0032 SCORING MRI STRUCTURAL LESIONS IN SACROILIAC JOINTS OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS: HOW MANY SLICES ARE OPTIMAL?

Background:

There is no international consensus on the optimal number of slices for evaluation of MRI structural lesions in the SIJ. An “all slice” method evaluates lesions from the most anterior slice, defined as the first slice with vertical height of ≥1cm of the SIJ joint cavity, up to the most posterior slice, defined as the most posterior slice where ≥1cm vertical height of the cartilaginous portion is still visible. The SPARCC method scores the transitional slice between cartilaginous and ligamentous compartments as the first slice and then an additional 4 slices anterior to the transitional slice.

Objectives:

We aimed to investigate inter-reader reliability, the extent of detection of lesions, and frequency of cases with a positive MRI for structural lesions when using an “all slice” approach versus the SPARCC scoring of 5 central slices.

Methods:

MRI T1W images with DICOM series were available from 148 cases who had MRI performed in the ASAS-Classification Cohort. Seven central readers recorded MRI lesions in an eCRF that recorded global assessments of presence/absence of changes suggestive of axSpA and structural lesions typical of axSpA. Structural lesions per the ASAS definitions were also recorded in consecutive semicoronal slices using the “all slice” approach, but also recording the transitional slice, according to their presence/absence in SIJ quadrants (erosion, fat lesion, sclerosis) or halves (backfill, ankylosis). Structural lesion frequencies were assessed descriptively according to majority agreement (≥4/7) of central readers and also any 2 central readers. Reliability for detection of MRI lesions was compared between central and local readers using the ICC.

Results:

The mean (SD) (range) number of anterior and posterior slices peripheral to the 5 central slices was 1.0 (1.0) (0-4) and 2.2 (1.8) (0-6) per case, respectively. There were 2 cases (1.4%) where ≥2 readers scored structural lesions in peripheral slices but not in the 5 central slices. The mean percentage of the total structural lesion score that was captured by the 5 central slices was >75% for all types of lesions except ankylosis (59%) (Table 1). Inter-reader reliability was greater for all lesions when assessing the 5 central slices and especially for erosion and backfill (Table 1).

Conclusion:

The major component of structural lesion data is captured by assessment of 5 slices, which includes the transitional slice and the subsequent 4 anterior slices. Moreover, reliability for detection of structural lesions is substantially worse in peripheral slices.

MRI Lesion“All slice”Central 5 slicesPeripheral slicesP value central vs peripheral slicesP value“all slice” vs central slicesMean (SD) Lesion Score Per CaseErosion2.4 (4.5) (0-22.9)1.8(3.4) (0-17.1)0.6 (1.4) (0-10.1)<0.001< 0.001Fat lesion2.5 (5.9) (0-34.0)1.8 (4.5) (0-25.1)0.7 (1.8) (0-9.9)< 0.001<0.001Sclerosis2.0 (4.9) (0-39.0)1.5 (3.6) (0-26.1)0.5 (1.5) (0-12.9)< 0.001<0.001Backfill0.5 (1.5) (0-12)0.4 (1.2) (0.0-9.3)0.1 (0.4) (0-2.7)< 0.0010.84Ankylosis0.5 (3.4) (0-30.7)0.3 (2.3) (0-20.0)0.2 (1.2) (0-11.3)0.100.18Mean (SD) (Range) % of Total Lesion Score in Central vs Peripheral slicesErosion100%76.4% (28.9%) (0-100%)23.6% (28.9%) (0-100%)<0.001NAFat lesion100%75.4% (26.5%) (0-100%)24.6% (26.5%) (0-100%)<0.001NASclerosis100%79.5% (22.9%) (0-100%)20.5% (22.9%) (0-100%)<0.001NABackfill100%86.0% (20.2%) (0-100%)14.0% (20.2%)(0-100%)<0.001NAAnkylosis100%59.0% (36.4%) (0-100%)41.0% (36.4%) (0-100%)0.56NAICC of 7 readers (Mean (SD) (Range))MRI lesionAll slicesCentral 5 slicesPeripheral slicesErosion0.54 (0.15) (0.28-0.84)0.58 (0.13) (0.34-0.85)0.40 (0.17) (0.10-0.66)Fat lesion0.61 (0.18) (0.30-0.89)0.63 (0.16) (0.35-0.88)0.52 (0.20) (0.19-0.82)Sclerosis0.73 (0.18) (0.36-0.94)0.73 (0.16) (0.36-0.91)0.67 (0.19) (0.27-0.94)Backfill0.37 (0.21) (0.10-0.85)0.39 (0.19) (0.14-0.83)0.18 (0.23) (0.0-0.80)Ankylosis0.97 (0.02) (0.91-0.99)0.99 (0.01) (0.97-1.0)0.85 (0.10) (0.62-0.98)

Disclosure of Interests:

None declared.

OP0149 RELIABILITY AND RESPONSIVENESS OF TWO OMERACT WHOLE-BODY MRI SCORES OF ENTHESEAL AND JOINT INFLAMMATION IN THE KNEE REGION IN SPONDYLOARTHRITIS

Background:

Inflammation in peripheral joints and entheses is common in spondyloarthritis (SpA). Whole-body magnetic resonance imaging (WB-MRI) allows assessment of the overall inflammatory status of arthritis patients including joints and entheses. The OMERACT MRI Whole-body scoring system for Inflammation in Peripheral joints and Entheses (MRI-WIPE) [1] has been developed and validated for the entire body assessment, including the knee, but not separately validated for the knee joint region. Detailed MRI scoring systems exist for heels, hands and feet, but although knee arthritis is a key cause of functional impairment, no detailed scoring system has been validated for inflammatory arthritides. The Knee Inflammation MRI Scoring System (KIMRISS) [2] was developed and validated in osteoarthritis and demonstrated good reliability.

Objectives:

To perform region-based development of whole-body MRI through validation of two knee region scoring systems in SpA.

Methods:

Assessment of inflammation was performed in the knee region on sagittal WB-MRIs using 2 scoring systems, MRI-WIPE and KIMRISS (Figure 1), in 4 iterative multi-reader exercises. In the final exercise, images (psoriatic arthritis, axial and peripheral SpA) were obtained before and after TNF-inhibitor.

Results:

In the final exercise (exercise 4), reliability was mostly good for experienced readers with the overall highest interreader agreement in the previous exercise (exercise 3). Median pairwise single measure intraclass correlation coefficients for osteitis and synovitis/effusion for status/change were 0.71/0.48 (WIPE osteitis), 0.48/0.77 (WIPE synovitis/effusion), 0.59/0.91 (KIMRISS osteitis) and 0.92/0.97 (KIMRISS synovitis/effusion) (Table 1). Wilcoxon signed-rank test showed significant change in synovitis/effusion for both methods and they correlated significantly regarding status in osteitis (0.92, p<0.001) and synovitis/effusion (0.89, p=0.001) and change in synovitis/effusion (0.89, p<0.001). Standardized response mean was 0.74 (WIPE synovitis/effusion) and 0.78 (KIMRISS synovitis/effusion).

Table 1.

MRI-WIPE knee and KIMRISS interreader reliability for OMERACT exercises 3 and 4

MRI-WIPE KneeKIMRISSOsteitisSynovitis/effusionOsteitisSynovitis/effusionVariablesNo. patientsType of scoreMean scoreICCMean scoreICCMean scoreICCMean scoreICCExercise 39 readers11Status3.6 (0-16)0.57 (-0.06-0.98)1.8 (0-4)0.47 (0.05-0.85)32.3 (1-224)0.87 (0.66-0.99)29.9 (11-60)0.34 (-0.62-0.87)11Change1.1 (-2-6)0.53 (0.03-0.90)0 (-2-1)0.32 (-0.13-0.76)27.7 (-9-131)0.58 (-0.30-0.96)-1.6 (-33-11)0.48 (-0.32-0.95)Exercise 33 readers11Status3.1 (0-16)0.83 (0.71-0.97)2.5 (0-5)0.59 (0.51-0.71)34.4 (0-233)0.89 (0.83-0.99)36.5 (16-78)0.59 (0.08-0.86)11Change0.9 (-3-6)0.72 (0.57-0.83)0 (-2-1)0.63 (0.49-0.76)19.3 (-23-86)0.46 (0.18-0.83)-1.8 (-45-17)0.89 (0.82-0.95)Exercise 49 readers10Change-0.25 (-4-5)0.38 (-0.35-0.94)-1.0 (-3-1)0.30 (-0.43-0.89)-0.45 (-37-65)0.26 (-0.86-0.97)-14.7 (-48-0.20)0.48 (-0.39-0.99)20Status2.9 (0-7)0.50 (-0.01-0.84)2.1 (0-4)0.44 (-0.21-0.79)15.2 (0-66)0.35 (-0.04-0.89)55.6 (1-122)0.54 (0.01-0.96)Exercise 43 readers10Change0.2 (-2-6)0.48 (0.16-0.66)-1.4 (-5-0)0.77 (0.70-0.82)5.8 (-27-111)0.92 (0.90-0.94)-20.7 (-65-28)0.97 (0.96-0.98)20Status2.3 (0-6)0.71 (0.60-0.80)2.7 (0-5)0.48 (0.42-0.57)11.4 (0-36)0.59 (0.39-0.71)69.4 (1-153)0.91 (0.87-0.93)

Sum scores are mean (range) of the patients scores. ICC values are mean (range). ICC is 2-way mixed model, single measure, by absolute agreement.

Conclusion:

MRI-WIPE and KIMRISS may both be useful as part of modular whole-body evaluation in clinical studies.

References:

[1]Krabbe S et al. J Rheum. 2019;46(9):1215-21

[2]Jaremko JL et al. RMD Open. 2017;3(1):e000355

Acknowledgements:

We thank CARE Aarthritis Limited (carearthritis.com) for help with setting up the web-based scoring interface, the scoring exercises, and the web-based meetings. We thank all who participated in the SIG (Special Interest Group) virtual OMERACT meeting 29 October 2020. HMO, GDM and PGC are supported in part by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, United Kingdom. The views expressed in this study are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Disclosure of Interests:

Marie Wetterslev: None declared, Walter P Maksymowych Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Novartis, Pfizer and UCB, Robert G Lambert Consultant of: Parexel and Pfizer, Iris Eshed: None declared, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Maria Stoenoiu: None declared, Simon Krabbe: None declared, Paul Bird Speakers bureau: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Consultant of: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Violaine Foltz: None declared, Ashish Jacob Mathew: None declared, Frederique Gandjbakhch: None declared, Joel Paschke: None declared, Philippe Carron Speakers bureau: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Consultant of: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Grant/research support from: UCB, MSD and Pfizer, Gabriele De Marco: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Grant/research support from: Janssen and Novartis, Anna Enevold Fløistrup Poulsen: None declared, Jacob L Jaremko: None declared, Philip G Conaghan Speakers bureau: AbbVie, AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer and Stryker, Consultant of: AbbVie, AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer and Stryker, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

OP0252 ARTHRITIS AND ENTHESITIS IN THE HIP AND PELVIS REGION IN SPONDYLOARTHRITIS – VALIDATION OF TWO WHOLE-BODY MRI METHODS

Background:

Whole-body MRI (WB-MRI) allows assessment of the overall inflammation in arthritis patients, including joint and entheses. To enhance the use of WB-MRI in clinical trials, the OMERACT MRI in Arthritis Working Group developed the OMERACT MRI Whole-body score for Inflammation in Peripheral joints and Entheses in inflammatory arthritis (MRI-WIPE) [1]. This has been validated for the entire body, including the hip/pelvis region, but not for each individual region. More detailed scoring systems exist for heels, hands and feet but although hip arthritis is a key cause of functional impairment in spondyloarthritis (SpA), no detailed scoring system has been published for use in SpA. The Hip Inflammation Magnetic Resonance Imaging Scoring System (HIMRISS) was developed and validated in osteoarthritis showing good reliability.

Objectives:

To validate reliability, correlation and responsiveness of two WB-MRI scores for the hip/pelvis region in SpA.

Methods:

Inflammation in the hip/pelvis region was assessed on coronal WB-MRIs in 4 iterative multi-reader exercises using MRI-WIPE for the hip/pelvis region and HIMRISS (Figure 1). In final exercises, images (axial/peripheral SpA and psoriatic arthritis) were obtained before and after TNF-inhibitor.

Results:

In final exercises reliability was mostly good for the best calibrated readers. Median single-measure intraclass correlation coefficients were 0.58-0.65 (WIPE osteitis), 0.10-0.88 (HIMRISS osteitis), 0.38-0.72/0.52-0.60 (WIPE synovitis/effusion) and 0.68-0.89/0.78-0.85 (HIMRISS synovitis/effusion) (Table 1). The methods correlated significantly for status in osteitis (0.72, p=0.019) and for synovitis/effusion status (0.83, p=0.003) and change (0.73, p=0.017) (Table 1). In exercise 4 Wilcoxon signed-rank test showed significant change in osteitis between timepoints using WIPE hip/pelvis and SRM was large (1.23), while lower for WIPE synovitis/effusion and HIMRISS.

Table 1.

MRI-WIPE hip/pelvis and HIMRISS interreader reliability for OMERACT exercises 3-4

MRI-WIPE hip/pelvisHIMRISSOsteitisSynovitis/effusionOsteitisSynovitis/effusionVariablesNo. patients(cases)Type of scoreMeanscoreICCMeanscoreICCMeanscoreICCMeanscoreICCExercise 39 readers11Status2.3 (0-10)0.69 (0.23-0.93)1.4 (0-4)0.58 (-0.06-0.96)8.2 (1-60)0.84 (0.56-0.99)12.8 (3-25)0.52 (0.00-.91)11Change-0.2 (-1-1)NA-0.2 (-3-1)0.50 (0.10-0.87)-0.35 (-3-1)NA-1.8 (-17-10)0.50 (-0.05-0.89)Exercise 33 readers11Status1.8 (0-10)0.63 (0.46-0.93)1.7 (0-5)0.60 (0.34-0.80)6.6 (0-65)0.88 (0.77-0.94)12.8 (2-28)0.89 (0.87-0.91)11Change-0.12 (-1-1)NA-0.12 (-3-2)0.60 (0.48-0.83)-0.7 (-7-0)NA-1.6 (-21-8)0.78 (0.70-0.87)Exercise 49 readers10 (1-10)Status1.2 (0-4)0.21 (-0.39-0.91)1.1 (0-2)0.19 (-0.31-0.69)1.8 (0-6)0.07 (-0.17-0.83)16.4 (9-23)0.31 (0.00-0.89)10 (11-20)Status1.6 (0-6)0.51 (-0.08-0.99)1 (0-3)0.40 (-0.17-0.88)3.5 (1-8)0,08 (-0.21-0.95)11.2 (5-24)0.49 (0.00-0.94)10 11-20)Change-0.4 (-2-0)NA-0.39 (-2-0)0.22 (-0.68-0.83)-2.2 (-7-2)NA-5.2 (-18-0)0.57 (0.02-0.92)20 (1-20)Status1.4 (0-6)0.41 (-0.35-0.92)1.0 (0-3)0.27 (-0.07-0.75)2.7 (0-9)0.09 (-0.17-0.85)13.8 (5-25)0.45 (0.01-0.90)Exercise 43 readers10 (1-10)Status0.8 (0-4)0.29 (0.01-0.78)1.3 (0-2)-0.02 (-0.29-0.12)0.4 (0-2)-0.04 (-0.04-0.04)15.8 (5-26)0.73 (0.59-0.89)10 (11-20)Status1.8 (0-9)0.65 (0.52-0.76)1.2 (0-4)0.72 (0.62-0.81)1.7 (0-5)0.06 (-0.17-0.35)9.2 (2-26)0.68 (0.53-0.88)10 (11-20)Change-0.6 (-2-0)NA-0.5 (-3-1)0.52 (0.49-0.55)-0.2 (-2-1)NA-2.8 (-19-6)0.85 (0.82-0.88)20 (1-20)Status1.3 (0-9)0.58 (0.43-0.69)1.2 (0-4)0.38 (0.31-0.44)1.0 (0-5)0.10 (-0.09-0.33)12.5 (2-26)0.73 (0.69-0.77)

Sum scores and ICCs are mean (range). ICC is 2-way mixed, single measure, by absolute agreement.

Conclusion:

MRI-WIPE and HIMRISS may be useful tools in modular WB-MRI evaluation of hip/pelvis inflammation in clinical trials in SpA.

References:

[1]Krabbe S et al. J Rheum. 2019;46(9):1215-21

[2]Jaremko JL et al. J Rheum. 2019;46(9)1239-42

Acknowledgements:

We thank CARE Arthritis Limited (carearthritis.com) for help with setting up the web-based scoring interface, scoring exercises, and the web-based meetings. We acknowledge the contribution of SIG (Special Interest Group) participants at the virtual OMERACT meeting October 29, 2020. HMO, GDM and PGC are supported in part by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, United Kingdom. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Disclosure of Interests:

Marie Wetterslev: None declared, Robert G Lambert Consultant of: Parexel and Pfizer, Walter P Maksymowych Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Novartis, Pfizer and UCB, Iris Eshed: None declared, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Paul Bird Speakers bureau: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Consultant of: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Maria Stoenoiu: None declared, Simon Krabbe: None declared, Ashish Jacob Mathew: None declared, Violaine Foltz: None declared, Frederique Gandjbakhch: None declared, Joel Paschke: None declared, Gabriele De Marco: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Grant/research support from: Janssen and Novartis, Philippe Carron Speakers bureau: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Consultant of: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Grant/research support from: UCB, MSD and Pfizer, Anna Enevold Fløistrup Poulsen: None declared, Jacob L Jaremko: None declared, Philip G Conaghan Speakers bureau: AbbVie, BMS, Eli Lilly, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Regeneron, Stryker, Consultant of: AbbVie, BMS, Eli Lilly, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Regeneron, Stryker, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

POS0037 DOES IMAGING OF THE SACROILIAC JOINT DIFFER IN PATIENTS PRESENTING WITH UNDIAGNOSED BACK PAIN AND PSORIASIS, ACUTE ANTERIOR UVEITIS, AND COLITIS: AN INCEPTION COHORT STUDY

Background:

Axial spondyloarthritis (axSpA) presents diagnostic challenges incurring a delay of up to a decade and relies considerably on radiographic and MRI evidence of sacroiliitis which has led to the development of classification criteria which also rely on imaging. However, it has been suggested that such criteria may not be appropriate for axSpA patients presenting with other forms of SpA, especially psoriatic, because imaging features may vary in frequency and/or may be atypical. This hypothesis has never been tested in a prospective inception cohort of patients presenting with undiagnosed back pain.

Objectives:

We aimed to compare the spectrum of radiographic and MRI abnormalities in the sacroiliac joint (SIJ) of an inception cohort of patients presenting with undiagnosed back pain and psoriasis, iritis, and colitis.

Methods:

We used data from the prospective multicenter Screening for Axial Spondyloarthritis in Psoriasis, Iritis, and Colitis (SASPIC) Study, which is aimed at early detection of axial SpA in patients referred by the respective specialist after first presenting with these disorders. Consecutive patients ≤45 years of age with ≥3 months undiagnosed back pain with any one of psoriasis, AAU, or colitis undergo routine clinical evaluation by a rheumatologist for axial SpA followed by imaging. In SASPIC I, MRI evaluation of the SIJ was ordered per rheumatologist decision. In SASPIC II, MRI evaluation was ordered for all patients. Radiographs and MRI scans were assessed by two central readers and comparisons of the three groups were based on concordant assessments of imaging features. Evaluation of MRI scans included both global assessment for presence/absence of axSpA with confidence scale (-10 to +10), active and structural lesions typical of axSpA per recent ASAS definitions, and granular assessment of individual lesions according to SIJ quadrants and halves in consecutive semicoronal slices through the SIJ. Groups were compared by ANOVA and the chi-square test.

Results:

A total of 240 patients were recruited, 143 from SASPIC I and 97 from SASPIC II, 101 (42.1%) being diagnosed with axSpA (65.3% male, mean age 34.4 years, mean symptom duration 8.7 years, B27 positive 55.4%). Mean age of colitis (N=101), psoriasis (N=61), iritis (N=78) patients were 33.4, 36.6, 34.3 years, respectively, mean symptom duration was 6.8, 7.2, 9.4 years, respectively, and % males were 45.5%, 52.5%, 51.3%, respectively. There were no significant group differences for unilateral versus bilateral radiographic sacroiliitis and no significant differences in the frequencies, type, or distribution of MRI lesions (Table 1).

Conclusion:

Data from the SASPIC prospective inception cohort does not support the view that imaging of the SIJ differs in psoriatic axSpA, which appears similar to axSpA associated with iritis or colitis. These data support the umbrella concept of axSpA.

Imaging FeatureColitis (n=30)Psoriasis (n=19)Iritis (n=52)P valueUnilateral sacroiliitis (grade ≥2), N(%)1 (3.3%)0 (0%)2 (3.8%)0.69mNY criteria +, N(%)5 (16.7%)6 (31.2%)15 (28.8%)0.39Grade of sacroiliitis, mean(SD)1.8 (2.2)2.1 (2.7)2.2 (2.4)0.76MRI indicative of axSpA, N(%)15 (50.0%)11 (57.9%)32 (61.5%)0.60MRI indicative of axSpA (confidence ≥5/10), N(%)14 (46.7%)10 (52.6%)30 (57.7%)0.63MRI active lesion typical of axSpA, N(%)6 (20.0%)6 (31.6%)18 (34.6%)0.37MRI structural lesion typical of axSpA, N(%)11 (36.7%)7 (36.8%)18 (34.6%)0.98MRI with unilateral lesion (any)2 (6.7%)3 (15.8%)11 (21.2%)0.22MRI with unilateral lesion (BME)1 (3.3%)2 (10.5%)5 (9.6%)0.54MRI with unilateral lesion (Erosion)0 (0%)0 (0%)3 (5.8%)0.23MRI with unilateral lesion (Sclerosis)1 (3.3%)1 (5.3%)3 (5.8%)0.89MRI with unilateral lesion (Fat)0 (0%)0 (0%)0 (0%)NAMRI with iliac lesion17 (56.7%)12 (63.2%)32 (61.5%)0.88MRI with sacral lesion12 (40.0%)11 (57.9%)31 (59.6%)0.21

Disclosure of Interests:

Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, BMS, Boehringer, Galapagos, Gilead, Lilly, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer, Ulrich Weber: None declared, Jon Chan: None declared, Raj Carmona: None declared, James Yeung: None declared, Sibel Aydin: None declared, Jodie Reis: None declared, Liam Martin: None declared, Ariel Masetto: None declared, Olga Ziouzina: None declared, Dianne Mosher: None declared, Stephanie Keeling: None declared, Sherry Rohekar: None declared, Rana Dadashova: None declared, Joel Paschke: None declared, Amanda Carapellucci: None declared, Robert G Lambert: None declared.

Tumor Necrosis Factor Inhibitors Reduce Spinal Radiographic Progression in Patients With Radiographic Axial Spondyloarthritis: A Longitudinal Analysis From the Alberta Prospective Cohort

Objective

To investigate whether tumor necrosis factor inhibitors (TNFi) impact spinal radiographic progression in patients with axial spondyloarthritis (SpA) and whether this is coupled to their effect on inflammation.

Methods

Patients with axial SpA fulfilling the modified New York criteria were included in a prospective cohort (the ALBERTA Follow Up Research Cohort in Ankylosing Spondylitis Treatment). Spine radiographs, performed every 2 years for up to 10 years, were scored by 2 central readers, using the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). The indirect effect of TNFi on mSASSS was evaluated with generalized estimating equations by testing the interaction between TNFi and Ankylosing Spondylitis Disease Activity Score (ASDAS) at the start of each 2‐year interval (t). If significant, the association between ASDAS at t and mSASSS at the end of the interval (t+1) was assessed in 1) patients treated with TNFi at all visits, 2) patients treated with TNFi at some visits, and 3) patients who were never treated with TNFi. In addition, the association between TNFi at t and mSASSS at t+1 (adjusting for ASDAS at t) was also tested (direct effect).

Results

In total, 314 patients were included. A gradient was seen for the effect of ASDAS at t on mSASSS at t+1 (interaction P = 0.10), with a higher progression in patients never treated with TNFi (β = 0.41 [95% confidence interval (95% CI) 0.13, 0.68]) compared to those continuously treated (β = 0.16 [95% CI 0.00, 0.31]) (indirect effect). However, TNFi also directly slowed progression, as treated patients had on average an mSASSS 0.85 units lower at t+1 compared to untreated patients (β = −0.85 [95% CI −1.35, −0.35]).

Conclusion

Our findings indicate that TNFi reduce spinal radiographic progression in patients with radiographic axial SpA, which might be partially uncoupled from their effects on inflammation as measured by the ASDAS.

Arthritis and enthesitis in the hip and pelvis region in spondyloarthritis - OMERACT validation of two whole-body MRI methods

OBJECTIVE

To validate reliability, correlation and responsiveness of two whole-body MRI scores for the hip/pelvis region in spondyloarthritis.

METHODS

Assessment of hip/pelvis inflammation in 4 multi-reader exercises using the OMERACT MRI Whole-body score for Inflammation in Peripheral joints and Entheses (MRI-WIPE) and Hip Inflammation Magnetic Resonance Imaging Scoring System (HIMRISS).

RESULTS

In exercises 3-4 (11/20 cases, respectively; 9 readers) reliability was mostly good for the 3 best calibrated readers. Median pairwise single-measure ICC for status were 0.58-0.65 (WIPE-osteitis), 0.10-0.88 (HIMRISS-osteitis) and for status/change 0.38-0.72/0.52-0.60 (WIPE-synovitis/effusion) and 0.68-0.89/0.78-0.85 (HIMRISS-synovitis/effusion). SRM was 1.23 for WIPE-osteitis, while lower for WIPE-synovitis/effusion and HIMRISS.

CONCLUSION

MRI-WIPE and HIMRISS may after further validation be useful in future spondyloarthritis trials.

Utility of magnetic resonance imaging in Crohn's associated sacroiliitis: A cross-sectional study

OBJECTIVE

Prevalence of sacroiliitis in Crohn's disease (CD) is variable depending on defining criteria. This study utilized standardized sacroiliac joint (SIJ) magnetic resonance imaging (MRI) to identify sacroiliitis in CD patients and its association with clinical and serological markers.

METHODS

Consecutive adult subjects with CD prospectively enrolled from an inflammatory bowel disease clinic underwent SIJ MRI. Data collected included CD duration, history of joint/back pain, human leukocyte antigen-B27 status, Bath Ankylosing Spondylitis Metrology Index (BASMI), Bath Ankylosing Spondylitis Disease Activity Index, Harvey Bradshaw Index (HBI) for activity of CD, Ankylosing Spondylitis Disease Activity Score, and various serologic markers of inflammation. Three blinded readers reviewed MRIs for active and structural lesions according to the Spondyloarthritis Research Consortium of Canada modules.

RESULTS

Thirty-three CD patients were enrolled: 76% female, 80% White, median age 36.4 years (interquartile range 27.2-49.0), moderate CD activity (mean HBI 8.8 ± SD 4.5). Nineteen subjects (58%) reported any back pain, 13 of whom had inflammatory back pain. Four subjects (12%) showed sacroiliitis using global approach and 6 (18%) met Assessment of SpondyloArthritis international Society MRI criteria of sacroiliitis. Older age (mean 51.2 ± SD 12.5 vs. 37.2 ± 14; P = .04), history of dactylitis (50.0% vs. 3.4%, P = .03) and worse BASMI (4.1 ± 0.7 vs. 2.4 ± 0.8, P ≤ .001) were associated with MRI sacroiliitis; no serologic measure was associated.

CONCLUSION

There were 12%-18% of CD patients who had MRI evidence of sacroiliitis, which was not associated with back pain, CD activity or serologic measures. This data suggests that MRI is a useful modality to identify subclinical sacroiliitis in CD patients.

SAT0378 THE RELATIVE DIAGNOSTIC UTILITY OF INFLAMMATORY BACK PAIN CRITERIA IN AN INCEPTION COHORT OF PATIENTS WITH PSORIASIS, IRITIS, AND COLITIS PRESENTING WITH UNDIAGNOSED BACK PAIN

Background:

Clinicians rely on the elicitation of features of inflammatory back pain (IBP) for diagnosis of axial spondyloarthritis (axSpA) but the utility of IBP criteria in patients presenting with extra-articular features of axSpA remains unclear. Assessment of utility should include not only rheumatologist diagnosis as benchmark but imaging to address the circularity between elicitation of IBP and clinical diagnosis.

Objectives:

To assess the diagnostic utility of all criteria for IBP in patients with psoriasis, iritis, or colitis and undiagnosed back pain using the rheumatologist diagnosis and imaging as benchmarks.

Methods:

Consecutive patients (n=246) with undiagnosed back pain ≤45 years of age, ≥3 months, with any one of psoriasis (n=46), acute anterior uveitis (AAU)(n=73), or colitis (n=127) had diagnostic evaluation by a rheumatologist. Majority central reader assessment of MRI indicative of axSpA and diagnosis by the rheumatologist were external standards for testing the utility of these IBP criteria: ASAS, Berlin, Calin, rheumatologist global for IBP >5 (0-10 scale).

Results:

AxSpA was diagnosed in 44.4%, 61.6%, and 41.8% of patients with psoriasis, iritis, and IBD, respectively. Diagnostic utility for all IBP criteria was comparably poor (Table 1). MRI was indicative of axSpA in 21.2%, 43.5%, and 19.7% of patients with psoriasis, iritis, and IBD. The utility of the IBP criteria was even worse using MRI as the external reference (Table 2), especially in patients with psoriasis. Only 14% of psoriasis patients with a positive MRI reported “improvement with exercise but not rest” as compared to 70% and 62% of patients with iritis and IBD, respectively.

Table 1.

Rheumatologist diagnosis as external reference.

SensitivitySpecificityLR+LR-PsoriasisASAS IBP65.00%52.00%1.350.67Berlin IBP80.00%36.00%1.250.56Calin IBP80.00%28.00%1.110.71All 3 criteria sets60.00%56.00%1.360.71IBP global >585.00%36.00%1.330.42AAUASAS IBP84.44%42.86%1.480.36Berlin IBP80.00%57.14%1.870.35Calin IBP93.33%17.86%1.140.37All 3 criteria sets77.78%60.71%1.980.37IBP global >586.67%57.14%2.020.23IBDASAS IBP78.43%45.07%1.430.48Berlin IBP82.35%52.11%1.720.34Calin IBP84.31%19.72%1.050.80All 3 criteria sets70.59%57.75%1.670.51IBP global >580.39%66.20%2.380.30Table 2.

Central assessment that MRI is indicative of axSpA as external reference.

SensitivitySpecificityLR+LR-PsoriasisASAS IBP28.57%38.46%0.461.86Berlin IBP42.86%15.38%0.513.71Calin IBP71.43%23.08%0.931.24All 3 criteria sets14.29%42.31%0.252.03IBP global >585.71%23.08%1.110.62AAUASAS IBP75.00%26.92%1.030.93Berlin IBP70.00%38.46%1.140.78Calin IBP90.00%15.38%1.060.65All 3 criteria sets65.00%38.46%1.060.91IBP global >575.00%38.46%1.220.65IBDASAS IBP92.31%37.74%1.480.20Berlin IBP76.92%39.62%1.270.58Calin IBP92.31%16.98%1.110.45All 3 criteria sets76.92%45.28%1.410.51IBP global >592.31%47.17%1.750.16

Conclusion:

All IBP criteria have poor diagnostic utility for diagnosis of axSpA, especially in patients with psoriasis. This reinforces the desirability of less subjective assessment tools, especially imaging.

Disclosure of Interests:

Georg Kröber: None declared, Ulrich Weber: None declared, Raj Carmona: None declared, James Yeung: None declared, Jon Chan: None declared, Sibel Aydin: None declared, Liam Martin: None declared, Ariel Masetto: None declared, Stephanie Keeling: None declared, Olga Ziouzina: None declared, Sherry Rohekar: None declared, Rana Dadashova: None declared, Joel Paschke: None declared, Amanda Carapellucci: None declared, Robert G Lambert: None declared, Walter P. Maksymowych Grant/research support from: AbbVie, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Employee of: Chief Medical Officer of CARE Arthritis Limited, Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, and UCB

SAT0383 ENHANCED PERFORMANCE OF THE ASAS CLASSIFICATION CRITERIA BY DELETION OF NON-DISCRIMINATORY CLINICAL ITEMS: DATA FROM THE SCREENING IN AXIAL SPONDYLOARTHRITIS IN PSORIASIS, IRITIS, AND COLITIS COHORT

Background:

The ASAS classification criteria for axial spondyloarthritis (axSpA) have overall sensitivity/specificity of 82.9%/84.4% but component imaging and clinical arms differ in performance (66.2%/97.3% and 56.6%/83.3%, respectively)1.

Objectives:

We aimed to demonstrate that a data-driven elimination of SpA clinical features that were non-discriminatory in comparisons of patients diagnosed with and without axSpA in a prospective cohort of patients with undiagnosed back pain could enhance the performance of the criteria.

Methods:

We used data from the prospective multicenter Screening for Axial Spondyloarthritis in Psoriasis, Iritis, and Colitis (SASPIC) Study. Consecutive patients ≤45 years of age with ≥3 months undiagnosed back pain with any one of psoriasis, AAU, or colitis undergo routine diagnostic evaluation by a rheumatologist for axial SpA, including imaging assessed by central readers. Univariable and multivariable logistic regression analysis was performed to determine which clinical SpA features were/were not discriminatory for the final diagnosis of axSpA. We then compared the sensitivity and specificity of the ASAS criteria with and without these features.

Results:

A total of 246 patients were recruited, 47.6% being diagnosed with axSpA (61.5% male, age 33.7 years, symptom duration 7.6 years, B27 positive 52.1%). The following clinical SpA features were non-discriminatory between axSpA/not axSpA: NSAID response, family history of SpA, heel enthesitis, peripheral arthritis, dactylitis. Specificity of the clinical arm and the overall criteria increased from 82.2% to 86.8% without impacting sensitivity. This effect was particularly noteworthy in patients with lower degree of symptomatology (back pain severity <5/10, specificity increases from 76.7% to 90.7%), short symptom duration (<5 years, specificity increases from 78% to 84.7%), and in females (specificity increases from 80.6% to 86.1%).

Conclusion:

In a prospective cohort with a high pre-test probability of axSpA certain clinical SpA features were not helpful in discriminating a diagnosis of SpA from not-SpA. Deletion of these features from the list of SpA features used in the ASAS classification criteria enhanced the performance of the criteria, especially in female patients and those with early disease.

References:

[1]Rudwaleit et al. Ann Rheum Dis 2009;68: 777-83

Patient CategoryNumberASAS criteriaImaging armClinical armSenSpecSenSpecSensSpecAll patients2466582.236.897.750.482.2High confidence in diagnosis19073.884.547.598.256.384.5Patients with back pain ≥5/1016563.384.934.298.851.984.9Patients with back pain <58168.476.742.195.347.476.7Patients with symptom duration ≥5 years10371.285.735.697.156.285.7Patients with symptom duration <5 years14354.57838.698.340.978Males12968.184.247.298.248.684.2Females1176080.62097.253.380.6After deletion of ‘NSAID response’, ‘Family Hx SpA’, ‘heel enthesitis’, ‘peripheral arthritis’, ‘dactylitis’ SpA featuresAll patients2466586.836.897.750.486.8High confidence in diagnosis19073.887.347.598.256.387.3Patients with back pain ≥5/1016563.384.934.298.851.984.9Patients with back pain <58168.490.742.195.347.490.7Patients with symptom duration ≥5 years10371.288.635.697.156.288.6Patients with symptom duration <5 years14354.584.738.698.340.984.7Males12968.187.747.298.248.687.7Females1176086.12097.253.386.1

Disclosure of Interests:

Walter P. Maksymowych Grant/research support from: AbbVie, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Employee of: Chief Medical Officer of CARE Arthritis Limited, Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, and UCB, Raj Carmona: None declared, Jon Chan: None declared, James Yeung: None declared, Sibel Aydin: None declared, Liam Martin: None declared, Ariel Masetto: None declared, Olga Ziouzina: None declared, Stephanie Keeling: None declared, Sherry Rohekar: None declared, Rana Dadashova: None declared, Joel Paschke: None declared, Amanda Carapellucci: None declared, Robert G Lambert: None declared

FRI0298 ASAS MODIFICATION OF THE BERLIN ALGORITHM AND THE DUET ALGORITHM FOR DIAGNOSING AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE SCREENING IN AXIAL SPONDYLOARTHRITIS FOR PSORIASIS, IRITIS, AND COLITIS COHORT

Background:

Patients presenting with back pain and psoriasis, iritis, or colitis, represent a high-risk population for the presence of axial spondyloarthritis (axSpA). The Dublin Evaluation Tool (DUET)1, the Berlin algorithm2, and the ASAS modification of this algorithm3are recommended referral strategies aimed at early diagnosis of axSpA. DUET was developed for patients presenting with AAU. Validation of these algorithms in inception cohorts is limited.

Objectives:

1. To assess the performance of referral algorithms for diagnosis of axSpA when tested against the final local rheumatologist diagnosis in an inception cohort of patients presenting with undiagnosed back pain and extra-articular manifestations. 2. To determine whether different criteria for inflammatory back pain (IBP) impact the performance of the algorithms.

Methods:

The multicenter Screening for Axial Spondyloarthritis in Psoriasis, Iritis, and Colitis (SASPIC) Study at 11 sites is aimed at early detection of axial SpA in patients presenting with undiagnosed back pain to the rheumatologist. Consecutive patients ≤45 years of age with ≥3 months undiagnosed back pain with any one of psoriasis, acute anterior uveitis (AAU), or colitis diagnosed by the relevant specialist undergo routine clinical evaluation by a rheumatologist for axial SpA. The rheumatologist determines the presence or absence of axial SpA at 3 consecutive stages: 1. After the clinical evaluation; 2. After the results of labs (B27, CRP) and radiography; 3. After the results of MRI evaluation. Final diagnosis by the rheumatologist was used as external standard to test the performance of the algorithms. We tested the following criteria for IBP in the algorithm: ASAS, Berlin, rheumatologist global for likelihood of IBP >5 (0-10 scale), and DUET algorithm in AAU patients.

Results:

A total of 246 patients were recruited, 73 presented with iritis, 46 with psoriasis, and 127 with colitis, 47.6% were diagnosed with axSpA. The diagnosis of axSpA was established in 45.7%, 61.6%, and 40.2% of patients with psoriasis, AAU, and IBD, respectively. The performance of the ASAS-modification of the Berlin algorithm was superior to the original algorithm as reported previously3, primarily for enhanced sensitivity, and this was observed irrespective of the criteria used to define IBP (Table 1). Conversely, the performance of the Duet algorithm in the subset of patients with AAU was substantially worse than previously reported1.

Conclusion:

The ASAS modification of the Berlin algorithm is the preferred referral strategy for patients presenting with undiagnosed back pain to the rheumatologist.

References:

[1]Haroon M, et al. Ann Rheum Dis 2015; 74: 1990-5

[2]Poddubnyy D, et al. J Rheumatol 2011; 38: 2452–60

[3]Van den Berg R, et al. Ann Rheum Dis 2013;72:1646–53

AlgorithmSensitivity (%)Specificity (%)Correct diagnosis (%)False negative (%)False positive (%)Original Berlin(ASAS criteria for IBP)65.376.671.116.712.2Original Berlin(Berlin criteria for IBP)64.476.670.717.112.2Original Berlin(IBP global >5)67.878.173.215.411.4ASAS Modification of Berlin algorithm (ASAS criteria for IBP)73.775.874.812.612.6ASAS Modification of Berlin algorithm (Berlin criteria for IBP)73.775.074.412.613.0ASAS Modification of Berlin algorithm(IBP global >5)76.377.376.811.411.8DUET84.450.071.29.619.2

Disclosure of Interests:

Ulrich Weber: None declared, Georg Kröber: None declared, Raj Carmona: None declared, James Yeung: None declared, Jon Chan: None declared, Sibel Aydin: None declared, Liam Martin: None declared, Ariel Masetto: None declared, Stephanie Keeling: None declared, Olga Ziouzina: None declared, Sherry Rohekar: None declared, Rana Dadashova: None declared, Amanda Carapellucci: None declared, Joel Paschke: None declared, Robert G Lambert: None declared, Walter P. Maksymowych Grant/research support from: AbbVie, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Employee of: Chief Medical Officer of CARE Arthritis Limited, Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, and UCB

FRI0302 WHAT IS THE IMPACT OF DISCREPANCY BETWEEN CENTRAL AND LOCAL READERS IN EVALUATION OF MRI SCANS ON THE CLASSIFICATION OF AXIAL SPONDYLOARTHRITIS? DATA FROM THE ASAS CLASSIFICATION COHORT STUDY

Background:

Active MRI lesions typical of axial spondyloarthritis (axSpA) were reported in 61.6% and 2.2% of axSpA and not-axSpA patients, respectively, from the ASAS classification cohort (ASAS-CC)1. Discrepancy between local and central reader evaluation of MRI scans could result in differences in numbers of patients fulfilling the imaging arm of the ASAS classification criteria. But final classification may not be impacted if discrepant patients still fulfill the clinical arm.

Objectives:

We aimed to assess the impact of reader discrepancy in detection of active MRI lesions on the number of patients classified as having axSpA in patients recruited to the ASAS-CC.

Methods:

MRI images of the sacroiliac joints (SIJs) were available from 252 cases in the ASAS-CC, and these also had clinical and radiographic data. Seven central readers from the ASAS-MRI group recorded MRI lesions in an eCRF that included active lesions typical of axSpA in the SIJ (MRI-active) that was worded exactly the same as in the original ASAS-CC eCRF permitting comparisons between central and local site readers. Active lesions were deemed to be present according to majority agreement (≥4/7) of central readers and also any 2 central readers. We calculated the number of patients that were classified differently after central evaluation for overall fulfilment of the ASAS criteria and for the imaging arm.

Results:

Discordance between central and local readers for detection of MRI-active was recorded in 45(17.8%) and 47(18.2%) of cases according to 2-reader and majority (≥4/7) central reader data, respectively (kappa (95%CI) of 0.64 (0.54-0.73) and 0.62 (0.53-0.72). With central reading as external standard the false-positive rate for active lesions was 26.9%% and 32.2% (‘local overcall’) for 2-reader and majority reader data, respectively. There were 159(63.1%) patients who fulfilled the ASAS axSpA criteria based on local-reading, and 148(58.7%) and 143(56.7%) patients based on 2-reader and majority central-reading, respectively (Table). When fulfillment of the imaging arm was the primary consideration (irrespective of the clinical arm), 126 (50%) patients fulfilled the criteria based on local-reading, and 111 (44%) and 102 (40.5%) patients based on 2-reader and majority central-reading, respectively.

Conclusion:

Despite substantial overcall for positive MRI SIJ inflammation by local readers, the number of patients classified as having axSpA did not change substantially. This is due to the alternate mechanism for classification through the clinical arm.

References:

[1]Rudwaleit et al. Ann Rheum Dis 2009;68: 777-83

Impact of Central Vs. Local Reader SIJ MRI Inflammation Assessment on SpA Classification in cases with all clinical, radiographic, and central and local MRI inflammation data available (n=252)MRI assessment usedSpA Classification = Yes N(%)SpA Classification = No N(%)Imaging Arm SpA Classification = Yes N(%)Imaging Arm SpA Classification = No N(%)Local Reader MRI positive159 (63.1%)93 (36.9%)126 (50%)126 (50%)>2 Central Reader MRI positive148 (58.7%)104 (41.3%)111 (44.0%)141 (56.0%)Majority Central Reader (≥4/7) MRI positive143 (56.7%)109 (43.2%)102 (40.5%)150 (59.5%)

Disclosure of Interests:

Walter P. Maksymowych Grant/research support from: AbbVie, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Employee of: Chief Medical Officer of CARE Arthritis Limited, Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, and UCB, Susanne Juhl Pedersen Grant/research support from: Novartis, Ulrich Weber: None declared, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Stephanie Wichuk: None declared, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Joel Paschke: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Robert G Lambert: None declared

OP0079 PRELIMINARY DEFINITION OF A POSITIVE MRI FOR STRUCTURAL LESIONS IN THE SACROILIAC JOINTS IN AXIAL SPONDYLOARTHRITIS

Background:

There is lack of international consensus as to what defines a structural lesion on MRI of the sacroiliac joints (SIJ) typical of axial spondyloarthritis (axSpA). The ASAS MRI group has generated updated consensus lesion definitions that describe each of the MRI lesions in the SIJ1. These definitions have been evaluated by 7 readers from the ASAS-MRI group on MRI images from the ASAS Classification Cohort.

Objectives:

We aimed to identify quantitative cut-offs based on numbers of slices and SIJ quadrants that define a positive MRI for structural lesions typical of axSpA, the gold standard being majority central reader decision as to the presence of a structural lesion typical of axSpA with high confidence.

Methods:

MRI structural lesions meeting ASAS definitions were recorded in an eCRF that comprises global assessment (structural lesion typical of axSpA present/absent and degree of confidence (-4 (absent) to +4 (present)), and detailed scoring of lesions per SIJ quadrant. Detailed scoring was based only on assessment of DICOM images (n =148). We calculated sensitivity and specificity for numbers of SIJ quadrants and consecutive slices with erosion, sclerosis, and fat lesions where a majority of readers (≥4/7) agreed as to the presence of a structural lesion typical of axSpA with high confidence (≥ +3). We tested candidate lesion definitions for predictive diagnostic utility in cases assessed after 4.4 years of follow up by the local rheumatologist.

Results:

Structural lesions typical of axSpA were observed by majority read in 33 (32.4%) of 102 cases diagnosed with axSpA, and 3 (6.8%) of 44 cases without axSpA and 29 cases were assigned a high degree of confidence (≥ +3) by a majority of readers. Cut-offs achieving specificity of 95% were erosion in ≥2 consecutive slices (sensitivity 83%), erosion ≥3 SIJ quadrants (sensitivity 90%), and fat lesion (≥1cm horizontal depth) in ≥1 SIJ quadrant (sensitivity 59%) (Table). These had very high positive predictive values (>95%) for diagnosis of axSpA in cases diagnosed by the rheumatologist after 4.4 years follow up.

Conclusion:

ASAS-defined erosion in ≥2 consecutive slices or in ≥3 SIJ quadrants and ASAS-defined fat lesion with depth >1cm in ≥1 SIJ quadrant are high priority candidates for defining an MRI structural lesion typical of axSpA. This will require similar assessment in additional axSpA cohorts.

References:

[1]Maksymowych et al. Ann Rheum Dis 2019; 78:1550-8.

Table 1.

Majority readers agree structural lesion indicative of axSpA is present with confidence ≥3/4 is the gold-standard external reference

SensitivitySpecificityErosion Score ≥1 SIJ qdr93.1 (77.2-99.2)80.6 (72.4-87.3)Erosion Score ≥2 SIJ qdr93.1 (77.2-99.2)90.8 (84.1-95.3)Erosion Score ≥3 SIJ qdr89.7 (72.6-97.8)95.8 (90.5-98.6)Erosion in 2 consecutive slices82.8 (64.2-94.2)95.0 (89.3-98.1)Fat lesion ≥1 SIJ qdr82.8 (64.2-94.2)81.5 (73.4-88.0)Fat lesion ≥2 SIJ qdr69.0 (49.2-84.7)86.6 (79.1-92.1)Fat lesion ≥3 SIJ qdr62.1 (42.3-79.3)91.6 (85.1-95.9)Fat lesion in 2 consecutive slices55.2 (35.7-73.6)93.3 (87.2-97.1)Fat lesion (>1cm depth) ≥158.6 (38.9-76.5)95.0 (89.3-98.1)Fat lesion (>1cm depth) ≥255.2 (35.7-73.6)95.8 (90.5-98.6)Fat lesion (>1cm depth) ≥351.7 (32.5-70.6)97.5 (92.8-99.5)Fat lesion (>1cm depth) in 2 consecutive slices48.3 (29.4-67.5)97.5 (92.8-99.5)

Table. SIJ qdr: sacroiliac joint quadrant

Disclosure of Interests:

Walter P. Maksymowych Grant/research support from: AbbVie, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Employee of: Chief Medical Officer of CARE Arthritis Limited, Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, and UCB, Xenofon Baraliakos: None declared, Ulrich Weber: None declared, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Susanne Juhl Pedersen Grant/research support from: Novartis, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Stephanie Wichuk: None declared, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Joel Paschke: None declared, Robert G Lambert: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB

Outcomes and Findings of the International Rheumatoid Arthritis (RA) BIODAM Cohort for Validation of Soluble Biomarkers in RA

OBJECTIVE

The Outcome Measures in Rheumatology Soluble Biomarker Working Group initiated an international, multicenter, prospective study, the Rheumatoid Arthritis (RA) BIODAM cohort, to generate resources for the clinical validation of candidate biomarkers predictive of radiographic progression. This first report describes the cohort, clinical outcomes, and radiographic findings.

METHODS

Patients with RA from 38 sites in 10 countries starting or changing conventional synthetic disease-modifying antirheumatic drugs and/or starting tumor necrosis factor inhibitors were followed for 2 years. Participating physicians were required to adhere to a treat-to-target strategy. Biosamples (serum, urine) were acquired every 3 months, radiography of hands and feet every 6 months, and ultrasound of hands and feet every 3 months in a subset. Primary endpoint was radiographic progression by the Sharp/van der Heijde score.

RESULTS

A total of 571 patients were recruited and 439 (76.9%) completed 2-year followup. At baseline, the majority was female (76%), mean age 55.7 years, and mean disease duration 6.5 years. Patients had a mean of 8.4 swollen and 13.6 tender joints, 44-joint count Disease Activity Score (DAS44) 3.8, 77.7% rheumatoid factor-positive or anticitrullinated protein antibody-positive. Percentage of patients in DAS and American College of Rheumatology remission at 2 years was 52.2% and 27.1%, respectively. Percentage of patients with radiographic progression (> 0.5) at 1 and 2 years was 38.2% and 59.9%, respectively.

CONCLUSION

The RA BIODAM prospective study succeeded in generating an extensive list of clinical, imaging (2343 radiographs), and biosample (4638 sera) resources that will be made available to expedite the identification and validation of biomarkers for radiographic damage endpoints. (Clinicaltrials.gov: NCT01476956, clinicaltrials.gov/ct2/show/NCT01476956).

SAT0384 REPLACEMENT OF RADIOGRAPHIC SACROILITIS BY MRI STRUCTURAL LESIONS: WHAT IS THE IMPACT ON CLASSIFICATION OF AXIAL SPONDYLOARTHRITIS IN THE ASAS CLASSIFICATION COHORT?

Background:

Classification of axial spondyloarthritis (axSpA) is based on either an imaging or clinical arm. Radiographic or MRI evidence of sacroiliitis can be applied for the imaging arm. However, it is well-established that reliability and sensitivity of radiographic sacroiliitis is inadequate.

Objectives:

To assess the impact of replacing radiographic sacroiliitis with MRI structural lesions (MRI-S) typical of axSpA on the number of patients classified as having axSpA in patients with undiagnosed back pain recruited to the ASAS Classification Cohort (ASAS-CC).

Methods:

MRI images of the sacroiliac joint (SIJ) were available from 217 cases in the ASAS-CC, which also had clinical, laboratory, and radiographic data. Seven central readers from the ASAS-MRI group recorded MRI lesions in an eCRF that included active (MRI-A) and structural (MRI-S) lesions typical of axSpA. MRI-A was deemed to be present according to majority agreement (≥4/7) of central readers. MRI-S was deemed to be present according to the majority (majority reader MRI-S) and also according to at least 2 central readers (≥2-reader MRI-S). We calculated the number of patients that were classified differently after replacement of radiographs by MRI-S for overall fulfillment of the ASAS criteria and for the imaging arm.

Results:

In total, 119 (54.8%) cases fulfilled the axSpA criteria based on local reading of radiographic sacroiliitis and central reading of active inflammation on MRI. This changed to 125 (57.6%) and 118 (54.4%) of cases after replacement of radiographic sacroiliitis by ≥2-reader and majority reader MRI-S, respectively (Table). A total of 13 (6.0%) and 7 (3.2%) cases who were classified as not having axSpA were re-classified as having axSpA after replacing radiographic sacroiliitis with ≥2-reader and majority reader MRI-S, respectively. Conversely, 7 (3.2%) and 8 (3.7%) cases were re-classified as not having axSpA after substitution by ≥2-reader and majority reader MRI-S, respectively. When fulfillment of the imaging arm was the primary consideration (irrespective of the clinical arm), the number of patients reclassified from not axSpA to axSpA was 25 (11.5%) by ≥2-reader and 13 (6.0%) by majority reader MRI-S, while 8 (3.7%) and 11 (5.1%) were reclassified from axSpA to not axSpA.

Conclusion:

The number of patients classified as having axSpA does not change substantially when MRI-S replaces radiographic sacroiliitis. However, it remains possible that MRI structural lesions can influence the final diagnosis, the gold standard for assessment of the performance of the ASAS criteria.

Impact of Replacement of Radiographic Sacroilitis by MRI Structural Lesions on SpA Classification in cases with all clinical, radiographic, and central and local MRI inflammation data available (n=217)

MRI assessment usedSpA Classification=Yes N(%)SpA Classification=No N(%)Imaging Arm SpA Classification=Yes N(%)Imaging Arm SpA Classification=No N(%)Radiographic Sacroiliitis + Majority Central Reader MRI Inflammation Positive119 (54.8%)97 (44.7%)83(38.2%)134 (61.8%)Replace Radiographic Sacroiliitis with ≥2 Central Reader MRI Structural Positive125 (57.6%)92 (42.4%)100 (46.1%)117 (53.9%)Replace Radiographic Sacroiliitis with Majority Central Reader MRI Structural Positive118 (54.4%)99 (45.6%)85 (39.2%)132 (60.8%)

Disclosure of Interests:

Walter P. Maksymowych Grant/research support from: AbbVie, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Employee of: Chief Medical Officer of CARE Arthritis Limited, Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, and UCB, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Robert G Lambert: None declared, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Stephanie Wichuk: None declared, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Martin Rudwaleit Consultant of: AbbVie, BMS, Celgene, Janssen, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB Pharma, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Robert B.M. Landewé Consultant of: AbbVie; AstraZeneca; Bristol-Myers Squibb; Eli Lilly & Co.; Galapagos NV; Novartis; Pfizer; UCB Pharma, Joel Paschke: None declared, Susanne Juhl Pedersen Grant/research support from: Novartis, Ulrich Weber: None declared

AB1358-HPR DIAGNOSIS OF AXIAL SPONDYLOARTHRITIS: A PRIMARY UNMET EDUCATIONAL NEED FOR RHEUMATOLOGISTS

Background:

Diagnosis of axial spondyloarthritis (axSpA) is challenging because of absent physical findings in early disease and the limited diagnostic performance of laboratory markers. Considerable reliance is placed on imaging of the sacroiliac joints (SIJ) but specialty training is primarily focused on interpretation of plain radiographic abnormalities.

Objectives:

We aimed to identify what might be the primary unmet educational needs of rheumatologists completing fellowship training by using clinical and imaging data from an inception cohort of patients presenting with undiagnosed back pain. We hypothesized that concordance would increase after imaging is reviewed after the clinical data.

Methods:

The diagnosis of axSpA was compared between local rheumatologists, axSpA experts and pF using clinical and imaging data from the multicenter Screening for Axial Spondyloarthritis in Psoriasis, Iritis, and Colitis (SASPIC) Study. In this inception cohort, patients ≤45 years of age with ≥3 months back pain undergo diagnostic evaluation by a local SASPIC rheumatologist, including imaging of the SIJ, who then records a global evaluation of presence/absence of axial SpA. This is done at 3 consecutive stages: 1.After the clinical evaluation. 2.After the results of labs (HLA B27, CRP) and radiography. 3.After review of the local MRI. In this exercise, 20 cases were selected from the SASPIC cohort and the rheumatologist global evaluations were removed from the eCRFs. Four experts in axSpA reviewed the clinical and imaging data in each eCRF and provided their global evaluations for stages 1, 2, and 3 of these 20 cases. Subsequently, 4 pF rheumatologists conducted the same exercise blinded to the assessments of the local rheumatologist and experts in axSpA. Concordance (% agreement) between the assessors was analyzed.

Results:

Diagnosis of axSpA by the local SASPIC rheumatologist was made in 90%, 65%, and 75% of cases after stages 1, 2, and 3, respectively. Majority diagnosis of axSpA by experts was made in 84.2% (16/19), 57.9% (11/19), and 63.2% (12/19), after stages 1,2, and 3, respectively. Majority diagnosis of axSpA by pF rheumatologists was made in 94.4% (17/18), 100% (16/16), and 93.8% (15/16). Concordance among experts and between experts and local SASPIC rheumatologists increased after review of imaging data. For pf-rheumatologists concordance with experts increased after review of imaging for 2 assessors and decreased for the other 2 assessors. For the latter, the primary reason for decrease in concordance with experts was false positive diagnosis of axSpA in 35% and 30% of the cases after review of the imaging.

Conclusion:

A structured case-based and sequential evaluation of clinical and imaging data suggests a gap in the training of recently graduated rheumatologists, with over-interpretation of imaging leading to false positive diagnosis of axSpA.

AssessorsMean % Concordance (range) for diagnosis of axSpAStage 1Stage 2Stage 3Experts in axSpA64.2 (45-80)75.8 (65-85)84.2 (70-95)Local rheumatologist vs Experts in axSpA73.8 (70-80)83.8 (80-85)83.8 (80-90)pF rheumatologist 1 vs Experts consensus78.994.494.7pF rheumatologist 2 vs Experts consensus89.561.168.4pF rheumatologist 3 vs Experts consensus63.272.284.2pF rheumatologist 4 vs Experts consensus89.566.768.4

Disclosure of Interests:

Walter P. Maksymowych Grant/research support from: AbbVie, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer, and UCB, Employee of: Chief Medical Officer of CARE Arthritis Limited, Speakers bureau: AbbVie, Janssen, Novartis, Pfizer, and UCB, Liron Caplan: None declared, Atul Deodhar Grant/research support from: AbbVie, Eli Lilly, GSK, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myer Squibb (BMS), Eli Lilly, GSK, Janssen, Novartis, Pfizer, UCB, Soha Dolatabadi: None declared, Mark Hwang: None declared, Adam Carlson: None declared, Kelly Steed: None declared, Amanda Carapellucci: None declared, Joel Paschke: None declared, Lianne S. Gensler Grant/research support from: Pfizer, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, GSK, Novartis, UCB

THU0105 ISOTOPE-LABELING-LC-MS-BASED METABOLIC PROFILING OF MULTIPLE SERUM SAMPLE SETS FOR THE DISCOVERY OF HIGH-CONFIDENCE RHEUMATOID ARTHRITIS BIOMARKERS

Background:

Early diagnosis of rheumatoid arthritis (RA) is hampered by suboptimal accuracy of currently available serological biomarkers. Metabolomics may reveal promising biomarker candidates associated with the biomolecular processes of RA. In this work, we applied a high-performance chemical isotope labeling (CIL) LC-MS technique for in-depth profiling of the amine/phenol-submetabolome in serum samples. To avoid false positives and obtain high-confidence biomarker candidates, we analyzed three independent sets of serum samples collected from RA patients and healthy controls to examine the common effects.

Objectives:

We aimed to identify a metabolite signature with consistently high accuracy for RA.

Methods:

Serum samples were taken from 3 RA cohorts, which comprised 50, 49, and 131 RA patients, respectively. Within each cohort, there were sex/age-matched healthy controls: 50 in Cohort 1, 50 in Cohort 2, and 100 in Cohort 3. Among these 446 subjects, 75% were females and the average age was 52.5 years. Amine/phenol-containing metabolites were labeled by12C-dansyl chloride to improve the LC-MS detection. For each cohort, a pooled sample was prepared and labeled by13C-dansyl group to serve as the reference sample for relative quantification. Then the individual samples and the pooled sample were mixed 1:1. Finally, an LC-QTOF-MS platform analyzed the mixtures and output the intensity ratios of12C/13C peak pairs.

Results:

1,149 amine/phenol-containing metabolites were commonly detected across the three sample sets. Among them, 134 were positively identified by our dansyl-labeling standard library, and 141 were matched to predicted retention times and mass values of dansyl-labeled human metabolites. Visualized by the partial least squares discriminant analysis (PLS-DA), the overall amine/phenol-submetabolome demonstrated clear and consistent differences between healthy controls and the RA groups, with cross-validation Q2 = 0.765, 0.745, 0.793, respectively. The selection of significant metabolites was conducted according to the fold change and false-discovery-rate-adjusted Welch’s t-test. Cohort 1 demonstrated 85 metabolites having higher concentrations in the RA samples than the controls, and 89 metabolites with lowered concentrations. The numbers of increased/decreased metabolites in Cohort 2 and 3 were 87/26 and 90/53, respectively. Importantly, there were 59 significantly discriminatory metabolites commonly found in the three data sets (49 increased and 9 decreased). We picked the top three with the highest univariate classification performance to form a biomarker panel. We implemented the linear support vector machine (SVM) to build the classifier and the receiver operating characteristic (ROC) analysis to measure the performance. The area-under-the-curve (AUC) values (95% confidence interval) were 1.000 (1.000-1.000), 0.992 (0.967-1.000) and 0.902 (0.858-0.945) for the three cohorts, respectively. The results revealed the importance of examining multiple sample sets and even in the worst case (Cohort 3), our biomarker candidates could differentiate RA at 82.5% sensitivity and 82.5% specificity. Particularly, in Cohort 3, there were 30 RA patients negative for anti-cyclic citrullinated peptide and rheumatoid factor, and our metabolite panel demonstrated consistently high performance for differentiating these specific subjects from healthy controls.

Conclusion:

Metabolites showing significant and consistent changes associated with RA have been identified with high discriminative power.

Disclosure of Interests:

Wei Han: None declared, Xiaohang Wang: None declared, Liang Li: None declared, Stephanie Wichuk: None declared, Edna Hutchings: None declared, Rana Dadashova: None declared, Joel Paschke: None declared, Walter P Maksymowych Grant/research support from: Received research and/or educational grants from Abbvie, Novartis, Pfizer, UCB, Consultant of: WPM is Chief Medical Officer of CARE Arthritis Limited, has received consultant/participated in advisory boards for Abbvie, Boehringer, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, UCB, Speakers bureau: Received speaker fees from Abbvie, Janssen, Novartis, Pfizer, UCB.

Is treat-to-target really working in rheumatoid arthritis? a longitudinal analysis of a cohort of patients treated in daily practice (RA BIODAM)

OBJECTIVES

To investigate whether following a treat-to-target (T2T)-strategy in daily clinical practice leads to more patients with rheumatoid arthritis (RA) meeting the remission target.

METHODS

RA patients from 10 countries starting/changing conventional synthetic or biological disease-modifying anti-rheumatic drugs were assessed for disease activity every 3 months for 2 years (RA BIODAM (BIOmarkers of joint DAMage) cohort). Per visit was decided whether a patient was treated according to a T2T-strategy with 44-joint disease activity score (DAS44) remission (DAS44 <1.6) as the target. Sustained T2T was defined as T2T followed in ≥2 consecutive visits. The main outcome was the achievement of DAS44 remission at the subsequent 3-month visit. Other outcomes were remission according to 28-joint disease activity score-erythrocyte sedimentation rate (DAS28-ESR), Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI) and American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean definitions. The association between T2T and remission was tested in generalised estimating equations models.

RESULTS

In total 4356 visits of 571 patients (mean (SD) age: 56 (13) years, 78% female) were included. Appropriate application of T2T was found in 59% of the visits. T2T (vs no T2T) did not yield a higher likelihood of DAS44 remission 3 months later (OR (95% CI): 1.03 (0.92 to 1.16)), but sustained T2T resulted in an increased likelihood of achieving DAS44 remission (OR: 1.19 (1.03 to 1.39)). Similar results were seen with DAS28-ESR remission. For more stringent definitions (CDAI, SDAI and ACR/EULAR Boolean remission), T2T was consistently positively associated with remission (OR range: 1.16 to 1.29), and sustained T2T had a more pronounced effect on remission (OR range: 1.49 to 1.52).

CONCLUSION

In daily clinical practice, the correct application of a T2T-strategy (especially sustained T2T) in patients with RA leads to higher rates of remission.

Atlas of the OMERACT Heel Enthesitis MRI Scoring System (HEMRIS)

Objective

Assessment of enthesitis, a key feature in spondyloarthritis (SpA) and psoriatic arthritis (PsA), using objective and sensitive methods is pivotal in clinical trials. MRI allows detection of both soft tissue and intra-osseous changes of enthesitis. This article presents an atlas for the Outcome Measures in Rheumatology (OMERACT) Heel Enthesitis Magnetic Resonance ImagingMRI Scoring System (HEMRIS).

Methods

Following a preliminary selection of potential examples of each grade, as per HEMRIS definitions, the images along with detailed definitions and reader rules were discussed at web-based, interactive meetings between the members of the OMERACT MRI in Arthritis Working Group.

Results

Reference images of each grade of the MRI features to be assessed using HEMRIS, along with reader rules and recommended MRI sequences are depicted.

Conclusion

The presented reference images can be used to guide scoring Achilles tendon and plantar fascia (plantar aponeurosis) enthesitis according to the OMERACT HEMRIS in clinical trials and cohorts in which MRI enthesitis is used as an outcome.

Adherence to Treat-to-target Management in Rheumatoid Arthritis and Associated Factors: Data from the International RA BIODAM Cohort

Objective.

Compelling evidence supports a treat-to-target (T2T) strategy for optimal outcomes in rheumatoid arthritis (RA). There is limited knowledge regarding the factors that impede implementation of T2T, particularly in a setting where adherence to T2T is protocol-specified. We aimed to assess clinical factors that associate with failure to adhere to T2T.

Methods.

Patients with RA from 10 countries who were starting or changing conventional synthetic disease-modifying antirheumatic drugs and/or starting tumor necrosis factor inhibitors were followed for 2 years. Participating physicians were required per protocol to adhere to the T2T strategy. Factors influencing adherence to T2T low disease activity (T2T-LDA; 44-joint count Disease Activity Score ≤ 2.4) were analyzed in 2 types of binomial generalized estimating equations models: (1) including only baseline features (baseline model); and (2) modeling variables that inherently vary over time as such (longitudinal model).

Results.

A total of 571 patients were recruited and 439 (76.9%) completed 2-year followup. Failure of adherence to T2T-LDA was noted in 1765 visits (40.5%). In the baseline multivariable model, a high number of comorbidities (OR 1.10, 95% CI 1.02–1.19), smoking (OR 1.32, 95% CI 1.08–1.63) and high number of tender joints (OR 1.03, 95% CI 1.02–1.04) were independently associated with failure to implement T2T, while anticitrullinated protein antibody/rheumatoid factor positivity (OR 0.63, 95% CI 0.50–0.80) was a significant facilitator of T2T. Results were similar in the longitudinal model.

Conclusion.

Lack of adherence to T2T in the RA BIODAM cohort was evident in a substantial proportion despite being a protocol requirement, and this could be predicted by clinical features. [Rheumatoid Arthritis (RA) BIODAM cohort; ClinicalTrials.gov: NCT01476956].

Development and Validation of an OMERACT MRI Whole-Body Score for Inflammation in Peripheral Joints and Entheses in Inflammatory Arthritis (MRI-WIPE)

OBJECTIVE

To develop a whole-body magnetic resonance imaging (MRI) scoring system for peripheral arthritis and enthesitis.

METHODS

After consensus on definitions/locations of MRI pathologies, 4 multireader exercises were performed. Eighty-three joints were scored 0-3 separately for synovitis and osteitis, and 33 entheses 0-3 separately for soft tissue inflammation and osteitis.

RESULTS

In the last exercise, reliability was moderate-good for musculoskeletal radiologists and rheumatologists with previously demonstrated good scoring proficiency. Median pairwise single-measure/average-measure ICC were 0.67/0.80 for status scores and 0.69/0.82 for change scores; κ ranged 0.35-0.77.

CONCLUSION

Whole-body MRI scoring of peripheral arthritis and enthesitis is reliable, which encourages further testing and refinement in clinical trials.

The OMERACT MRI in Enthesitis Initiative: Definitions of Key Pathologies, Suggested MRI Sequences, and a Novel Heel Enthesitis Scoring System

OBJECTIVE

To develop and validate an enthesitis magnetic resonance imaging (MRI) scoring system for spondyloarthritis/psoriatic arthritis, using the heel as model.

METHODS

Consensus definitions of key pathologies and 3 heel enthesitis multireader scoring exercises were done, separated by discussion, training, and calibration.

RESULTS

Definitions for bone and soft tissue pathologies were agreed. In the final exercise, median pairwise single-measures intraclass correlation coefficients (ICC; patient-level) for entheseal inflammation status/change scores were 0.83/0.82 for all readers. For radiologists and selected rheumatologists, ICC were 0.91/0.84 and quadratic-weighted κ (lesion-level) 0.57-0.91/0.45-0.81.

CONCLUSION

The proposed definitions and Heel Enthesitis Scoring System (HEMRIS) are reliable among trained readers and promising for clinical trials.

Feasibility and Reliability of the Spondyloarthritis Research Consortium of Canada Sacroiliac Joint Structural Score in Children

OBJECTIVE

There is a critical need for measures to evaluate structural progression in the pediatric sacroiliac joint (SIJ). We aimed to evaluate the construct validity and reliability of the Spondyloarthritis Research Consortium of Canada SIJ Structural Score (SSS) in children with suspected or confirmed juvenile spondyloarthritis.

METHODS

The SSS assesses structural lesions of the SIJ on magnetic resonance imaging (MRI) through the cartilaginous part of the joint. We conducted 3 sequential reading exercises with 6 readers (1 adult and 3 pediatric radiologists, 1 adult and 1 pediatric rheumatologist). Each exercise was preceded by a calibration module. Interobserver reliability was assessed using intraclass correlation coefficients (ICC). Prespecified acceptable reliability thresholds were ICC > 0.5 for erosion, backfill, and sclerosis, and ICC > 0.7 for ankylosis and fat metaplasia.

RESULTS

The SSS had face validity and was feasible to score in pediatric cases for all 3 reading exercises. Of the cases used in the 3 exercises, 58% were male and the median age was 14 years (range 6.8-18.7 yrs). After calibration, median ICC across all readers for each SSS component were the following: erosion 0.67 (interquartile range 0.54-0.80), backfill 0.33 (0.19-0.52), fat metaplasia 0.74 (0.62-0.85), sclerosis 0.63 (0.48-0.77), and ankylosis 0.44 (0.28-0.62). Prespecified reliability thresholds were achieved in the third exercise for erosion, sclerosis, and fat metaplasia but not for backfill or ankylosis.

CONCLUSION

The SSS was feasible to score and had acceptable reliability for pediatric SIJ MRI evaluation. The ICC improved with additional calibration and reading exercises, even for readers with limited experience.

Feasibility and reliability of the Spondyloarthritis Research Consortium of Canada sacroiliac joint inflammation score in children

BACKGROUND

Published methods for quantification of magnetic resonance imaging (MRI) evidence of inflammation in the sacroiliac joint lack validation in pediatric populations. We evaluated the reliability and construct validity of the Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joint inflammation score (SIS) in children with suspected or confirmed juvenile spondyloarthritis (JSpA).

METHODS

The SPARCC SIS measures the presence, depth, and intensity of bone marrow inflammation on MRI through the cartilaginous part of the joint. Six readers blinded to clinical details except age, participated in two reading exercises, each preceded by a calibration exercise. Inter-observer reliability was assessed using intraclass correlation coefficients (ICCs) and for pre-specified acceptable reliability the inraclass correlation coefficient (ICC) was > 0.8.

RESULTS

The SPARCC SIS had face validity and was feasible to score in pediatric cases in both reading exercises. Cases were mostly male (64%) and the median age at the time of imaging was 14.9 years. After calibration, the median ICC across all readers for the SIS total score was 0.81 (IQR 0.71-0.89). SPARCC SIS had weak correlation with disease activity (DA) as measured by the JSpADA (r = - 0.12) but discriminated significantly between those with and without elevated C-reactive protein (p = 0.03).

CONCLUSION

The SPARCC SIS was feasible to score and had acceptable reliability in children. The ICC improved with additional calibration and reading exercises, for both experienced and inexperienced readers.

Hip Inflammation MRI Scoring System (HIMRISS) to predict response to hyaluronic acid injection in hip osteoarthritis

OBJECTIVE

To assess predictors of response, according to hip MRI inflammatory scoring system (HIMRISS), in a sample of patients with hip osteoarthritis (OA) treated by hyaluronic acid (HA) injection.

METHOD

Sixty patients with hip OA were included. Clinical outcomes were assessed at baseline and three months after HA injection by WOMAC. On hip MRI performed before HA injection, bone marrow lesion (BML) and synovitis were assessed by HIMRISS by four readers. The inter-reader reliability of HIMRISS was for HIMRISS total, acetabular BML, femoral BML and synovitis-effusion respectively 0.86, 0.64, 0.83 and 0.78. Associations between MRI features and clinical data were assessed. Logistic regression (univariate and multivariate) was used to explore associations between MRI features and response to HA injection, according to WOMAC50 response at three months.

RESULTS

In total, 45.5% of patients met WOMAC50 response. Five adverse events were reported. At baseline, WOMAC function correlated significantly to HIMRISS synovitis-effusion (r=0.27, P=0.03). In univariate analysis, BML femoral according to binary assessment (P=0.025), HIMRISS BML femoral (P=0.0038), HIMRISS BML acetabular (P=0.042), HIMRISS total (P=0.0092) were associated negatively with WOMAC50 response. In multivariate analysis, adjusted for age and BMI, HIMRISS femoral BML (P=0.02) and HIMRISS total (P=0.016) were negatively associated with response. At a HIMRISS threshold of<15, 82% of patients were responders, with specificity SP=0.97, sensitivity SN=0.39, and positive and negative predictive values of 0.91 and 0.64, respectively.

CONCLUSION

HIMRISS is reliable for total scores and sub-domains. It permits identification of responders to HA injection in hip OA patients.