Consensus statement on the diagnosis and treatment of sclerosing diseases of the skin, Part 1: Localized scleroderma, systemic sclerosis and overlap syndromes

The term 'sclerosing diseases of the skin' comprises specific dermatological entities, which have fibrotic changes of the skin in common. These diseases mostly manifest in different clinical subtypes according to cutaneous and extracutaneous involvement and can sometimes be difficult to distinguish from each other. The present consensus provides an update to the 2017 European Dermatology Forum Guidelines, focusing on characteristic clinical and histopathological features, diagnostic scores and the serum autoantibodies most useful for differential diagnosis. In addition, updated strategies for the first- and advanced-line therapy of sclerosing skin diseases are addressed in detail. Part 1 of this consensus provides clinicians with an overview of the diagnosis and treatment of localized scleroderma (morphea), and systemic sclerosis including overlap syndromes.

An engineered glove to follow finger function in rheumatoid arthritis: an observational prospective study

The engineered Hand Test System (HTS) glove has shown high reliability in assessing the baseline functional status of rheumatoid arthritis (RA) hand. Starting from this achievement, the aim of the present observational prospective study was to assess the functionality of the single fingers of rheumatoid hand at follow-up. Eighty RA patients performed HTS glove tests at baseline and among these fifty-six patients were re-tested after 7 months. The HTS glove parameters [Touch Duration (TD), Movement Rate (MR), Inter Tapping Interval (ITI)] were correlated with disease activity and disability clinimetric indexes [Disease Activity Score 28 joint count-C-reactive protein (DAS28-CRP), Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI), Health Assessment Questionnaire-Disability Index (HAQ-DI), grip strength, visual analogue scale of pain (VAS), patient global assessment (PGA)], and with laboratory values. HTS glove parameters (TD, ITI, and MR) showed statistically significant correlations with clinimetric and clinical indexes at both time points (p < 0.05). During follow-up, a statistically significant variation of all HTS glove parameters for the fingers that have performed both the worst or best HTS test at baseline was detected (p < 0.05), while the mean HTS glove parameter values by considering all fingers did not show a statistically significant variation over time, as well as the traditional clinimetric indexes. Besides the objective role in assessing the RA hand function by integrating the traditional clinimetric indexes, the HTS glove seems a useful tool for evaluating worst or best finger function during time by measuring the movement speed.

Emerging nailfold capillaroscopic patterns in COVID-19: from acute patients to survivors

The SARS-CoV-2 infection causing the Coronavirus disease-19 (COVID-19) is characterized by a broad range of clinical manifestations, implicating microvascular damage with endothelial dysfunction and different organ involvement.

Nailfold capillaroscopy in the rheumatological current clinical practice in Italy: results of a national survey

This cross-sectional online study was designed by the study group on Capillaroscopy and Microcirculation in Rheumatic Diseases (CAP) of the Italian Society of Rheumatology (SIR) to provide an overview of the management of nailfold capillaroscopy in Italian rheumatology centers. Therefore, SIR distributed the survey to its members in July 2021, and each center's physician with the most expertise in capillaroscopy completed the questionnaire. The survey was completed by 102 centers, with at least one representative from each Italian region. Ninety-three centers perform capillaroscopy, and 52 (56) conduct more than 200 investigations annually. Seventy-eight (84%) of respondents have more than five years of experience with the technique, and 75 centers (80.6%) have received certification from specific national or international training courses. In 85 centers, a videocapillaroscope with 200x magnification is employed (91.4%). The average waiting period for the examination is 2.4 months, and less than 3 months in 64 of the locations (68.8%). The study demonstrates that capillaroscopy is an integral part of both the diagnostic phase of Raynaud's phenomenon and the monitoring of autoimmune connective tissue diseases (CTDs). However, the reporting methods and timing of patient followup are heterogeneous.

POS1232 LONG-TERM OUTCOMES OF COVID-19 VACCINATION IN PATIENTS WITH RARE AND COMPLEX CONNECTIVE TISSUE DISEASES: AN AD-INTERIM ANALYSIS OF ERN-ReCONNET VACCINATE STUDY

Background

Since the COVID-19 vaccination campaign was launched all over Europe, there has been general agreement on how benefits of SARS-CoV2 vaccines outweigh the risks in patients with rare connective tissue diseases (rCTDs). Yet, there is still limited evidence regarding safety and efficacy of such vaccines in these patients, especially in the long-term. For this reason, in the framework of ERN-ReCONNET, an observational long-term study (VACCINATE) was designed in order to explore the long-term outcome of COVID-19 vaccination in rCTDs patients. The consent form was developed thanks to the involvement of the ERN ReCONNET ePAG Advocates (European Patients Advocacy Group).

Objectives

To evaluate the safety profile of COVID-19 vaccination in rCTDs patients and the potential impact on disease activity. Primary endpoints were the prevalence of adverse events (AEs) and of disease exacerbations post-vaccination. Secondary endpoints were the proportion of serious adverse events (SAEs) and adverse events of special interest for COVID-19 (adapted from https://brightoncollaboration.us/wp-content/uploads/2021/01/SO2_D2.1.2_V1.2_COVID-19_AESI-update-23Dec2020-review_final.pdf)

Methods

The first ad-interim analysis of the VACCINATE study involved 9 ERN-ReCONNET Network centres. Patients over 18 years of age with a known rCTD and who received vaccine against COVID-19 were eligible for recruitment. Demographic data and diagnoses were collected at the time of enrolment, while the appearance of AEs and potential disease exacerbations were monitored after one week from each vaccination dose, and then after 4, 12 and 24 weeks from the second dose. A disease exacerbation was defined as at least one of the following: new manifestations attributable to disease activity, hospitalization, increase in PGA from previous evaluation, addition of corticosteroids or immunosuppressants.

Results

A cohort of 300 patients (261 females, mean age 52, range 18-85) was recruited. Systemic lupus erythematosus (44%) and systemic sclerosis (16%) were the most frequent diagnoses, followed by Sjogren’s syndrome (SS,12%), idiopathic inflammatory myositis (IMM,10%), undifferentiated connective tissue disease (UCTD,8%), mixed connective tissue disease (MCTD,4%), Ehlers-Danlos’s syndrome (EDS,4%), antiphospholipid syndrome (APS,2%). AEs appearing 7 days after the first and second doses were reported in 93 (31%) and 96 (32%) patients respectively, mainly represented by fatigue, injection site reaction, headache, fever and myalgia. Otitis, urticaria, Herpes Simplex-related rash, stomatitis, migraine with aura, vertigo, tinnitus and sleepiness were reported with very low frequency. Less than 2% of patients experienced AEs within 24 weeks from the second dose. No SAEs or AEs of special interest were observed in the study period. There were 25 disease exacerbations (8%), 7 of which severe. The highest number of exacerbations was observed after 4 weeks from the second dose (12 within week 4, 6 within week 12 and 7 within week 24). Disease exacerbation was most frequent in patients with EDS (33%) and MCTD (25%).

Conclusion

This preliminary analysis shows that COVID-19 vaccination is safe in rCTDs patients. AEs appear most often early after vaccination and are usually mild. Disease exacerbations are not frequent, but can be potentially severe and tend to occur most frequently within the first month after vaccination. Exacerbations can also occur 3-6 months after vaccination, although a causal relationship with the vaccination remains to be established. Our present data underline the importance of long-term observational studies.

Table 1.

AEs and disease exacerbations per disease

DiagnosisPatients enrolled (%) (n=300)EAs after 1st and 2nd dose (%)Exacerbations (%)APS25714EDS45033IIM10527MCTD44225SS12598SLE44698SSC16492UCTD850-

Acknowledgements

VACCINATE is a study promoted by the European Reference Network on rare and complex connective tissue diseases, ERN ReCONNET. This publication was funded by the European Union’s Health Programme (2014-2020)

Disclosure of Interests

None declared

AB0092 CTLA4-Ig PROMOTES THE M1-M2 SHIFT IN CULTURED MACROPHAGES OF RHEUMATOID ARTHRITIS PATIENTS WITH ACTIVE DISEASE: IN VITRO STUDY

Background

In rheumatoid arthritis (RA), macrophages play an important role in modulating the immunoinflammatory response through their polarization into “classically” (M1) or “alternatively activated” (M2) phenotypes and the release of pro-inflammatory cytokines (1). In the active inflammatory phase of RA, circulating intermediate monocytes and synovial tissue macrophages show a M1 phenotype, whereas MerTK+M2 macrophages seem to characterize the synovial tissue of RA patients under remission (2-4). In RA, CTLA4-Ig fusion protein (abatacept) reduces the pro-inflammatory activity of macrophages by interacting with the costimulatory molecule CD86 on surface cell membrane of activated cells, including macrophages (2).

Objectives

The in vitro study investigated the efficacy of CTLA4-Ig treatment to induce the shift from the M1 phenotype into an M2 phenotype in cultured monocyte-derived macrophages (MDMs) obtained from active RA patients.

Methods

Cultured MDMs obtained from peripheral blood mononuclear cells of 5 active RA patients (mean age 54±13 years) and 5 age-matched healthy subjects (HSs) after overnight stimulation with phorbol myristate acetate (5ng/ml), were treated with CTLA4-Ig at the concentrations of 100mg/mL or 500mg/mL for 3, 12, 24 and 48 hours. A part of cultured RA-MDMs as wells as cultured HS-MDMs were maintained in growth medium (RPMI at 10% of fetal bovine serum) without any treatment and used as unstimulated cells. Gene expression of CD80, CD86 and toll-like receptor-4 (TLR4), as M1 markers, as well as macrophage scavenger receptors (CD163, CD204), mannose receptor-1 (CD206), as surface M2 markers, and MerTK (functional M2 marker) were evaluated by quantitative real-time polymerase chain reaction (qRT-PCR). Protein synthesis of surface M2 markers was investigated by Western blotting. The statistical analysis was performed by Wilcoxon t-test.

Results

Cultured RA-MDMs showed a high basal gene expression of TLR4, CD80 and CD86 compared to HS-MDMs, confirming to be activated M1 macrophages. In these macrophages, CTLA4-Ig treatment downregulated the gene expression of M1 markers at both concentrations and all timings, but significantly limited to TLR4 and CD80 markers (500mg/mL,12 hours: p<0.05). Conversely, both concentrations of CTLA4-Ig significantly upregulated the gene expression of CD163, MerTK and CD206 (p<0.05), whereas only the high concentration of CTLA4-Ig significantly upregulated CD204 gene expression (p<0.05). The protein synthesis of all M2 surface markers was increased after 24 hours of treatment primarily by the high concentration of CTLA4-Ig, and significantly for CD204 and CD206 (p<0.05).

Conclusion

CTLA4-Ig treatment seems to exert an important anti-inflammatory effect by promoting the shift from a M1 to an M2 phenotype in cultured RA macrophages The results suggest a further mechanism for CTLA4-Ig in the modulation of the RA synovitis (5).

References

[1]Yang X et al. Cell Prolif. 2020;53:e12854.doi:10.111/cpr.12854.

[2]Kumar RA et al. Int. Immunol.2018;65:348-59.

[3]Boutet MA et al. Autoimmun Rev.2021;20:102758. doi: 10.1016/j.autrev.2021.102758.

[4]Alivernini S et al. Nat Med. 2020;26:1295-306. 5. Cutolo M et al. Arthritis Res Ther. 2009;11:R176; doi: 10.1186/ar2865.

Disclosure of Interests

Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Celgene, Pfizer, Boehringer Ingelheim, Samuele Tardito: None declared, Emanuele Gotelli: None declared, Paola Montagna: None declared, Rosanna Campitiello: None declared, Sabrina Paolino: None declared, Carmen Pizzorni: None declared, Alberto Sulli Grant/research support from: Laboratories Baldacci, Vanessa Smith Grant/research support from: Boehringer Ingelheim, Janssen-Cilag, Stefano Soldano: None declared

AB1160 IMPACT OF COVID-19 TREATMENTS ON PERIPHERAL CAPILLARY DENSITY EVALUATED BY NAILFOLD VIDEOCAPILLAROSCOPY

Background

Human SARS-CoV-2 infection can induce a wide spectrum of organ dysfunctions, including microvascular impairment [1]. S1 subunit of viral receptor-binding domain binds to the angiotensin-converting enzyme 2 receptor on endothelium and S2 subunit allows the virus to enter endothelial cells. The resulting breakdown of barrier integrity drives a cascade of inflammatory and thrombotic events, that aggravate the course of COVID-19 together with other risk factors [2-4]. Up to date, a lower capillary density has been reported in several distinct body districts, using sublingual video microscopy, ocular optical coherence tomography angiography, skin functional laser Doppler perfusion imaging and nailfold videocapillaroscopy (NVC) [5-8]. NVC examination has been performed in adult COVID-19 patients, however, without a control group [8].

Objectives

To confirm the statistical significance of the reduction in capillary density per linear millimeter evaluated by NVC in comparison with primary Raynaud’s phenomenon (PRP) patients and control subjects (CNT) and to evaluate the impact of an aggressive therapy against COVID-19 on the sparing in the number of capillaries.

Methods

Sixty-one COVID-19 survivors, thirty-one PRP patients and thirty CNT age and sex-matched underwent NVC analysis. Demographic and clinical data of COVID-19 survivors were collected with special regard to concomitant therapies, that included antivirals, antibiotics, anticoagulants and anti-inflammatory/immunomodulant drugs (glucocorticoids, hydroxychloroquine, IL-6 receptor antagonist). COVID-19 survivors were divided in two subgroups according to the severity of the active infection: thirty-four survivors with past mild-moderate disease (either unneedy for oxygen supplementation or need for Venturi mask) and twenty-seven survivors with past severe disease (need for Continuous Positive Airways Pressure and/or mechanical ventilation). The same Rheumatologist performed NVC evaluations in all patients and controls, using an optical probe, equipped with a 200x magnification lens and connected to a picture analysis software (Videocap, DS Medica, Milan, Italy). Absolute capillary number per linear millimeter was counted.

Results

COVID-19 survivors underwent NVC examination after a mean period of 126±53 days from the disease onset. Multivariate analysis showed differences in absolute capillary number per linear millimeter (p<0.001) after adjusting for age, sex, body mass index, comorbidities and concomitant drugs. The mean (± standard deviation) absolute nailfold capillary number per linear millimeter was significantly lower in severe (8.2±1.15) and mild-moderate (8.4±0.75) COVID-19 survivors than in both PRP (8.7±0.68) and CNT subjects (9.3±0.53) (p<0.001). The analysis of the impact of treatments on capillary density in the severe COVID-19 patients showed a positive trend (preservation of the capillary number) with antivirals (no: 7.8±1.53; yes: 8.5±0.64; p=0.35) and anti-IL-6 receptor antagonist administration (no: 7.8±1.36; yes: 8.6±0.74; p=0.16), while none of the other drugs was shown to be effective (glucocorticoids p = 0.46; antibiotics = 0.52; anticoagulants not evaluable as they were used in all COVID-19 patients).

Conclusion

SARS-CoV-2 infection seems associated to a significant capillary loss as distinctive NVC feature and data concerning the comparison of capillary density pre COVID-19 and post COVID-19 are desirable to reinforce this observation. The positive trend in saving the number of capillaries induced by aggressive anti-inflammatory therapies in COVID-19 survivors needs larger cohorts of patients.

References

[1]Rovas A et al. Angiogenesis. 2021;24:145-157.

[2]Raghavan S et al. Front Cardiovasc Med. 2021;8:687783.

[3]Cutolo M et al. RMD Open. 2020;6:e001454.

[4]Sulli A et al. Nutrients. 2021;13(3):717.

[5]Kanoore Edul VS et al. J Crit Care. 2021;61:73-75.

[6]Teo KY et al. Am J Ophtalmol. 2021;235:98-110.

[7]Sabioni L et al. Microvasc Res. 2021;134:104119.

[8]Natalello G et al. Microvasc Res. 2021;133:104071.

Disclosure of Interests

Emanuele Gotelli: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci S.p.a., Pietro Francesco Bica: None declared, Irene Schiavetti: None declared, Teresita Aloe’: None declared, Marco Grosso: None declared, Emanuela Barisione: None declared, Carmen Pizzorni: None declared, Sabrina Paolino: None declared, Vanessa Smith Grant/research support from: Boehringer Ingelheim, Janssen-Cilag, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Celgene, Pfizer, Boehringer Ingelheim

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

Background

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

Objectives

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

Methods

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

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

Table 1.

Adverse events of special interest (AESI).*

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

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

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

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

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

Results

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

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

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

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

Conclusion

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

Acknowledgements

Trial registration: NCT02585258 (clinicaltrials.gov).

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

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

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

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

Partners:

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

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

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

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

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

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

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

Investigators (other recruiting centers):

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

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

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

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

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

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

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

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

J. Costa, Hospital de Ponte Lima, Portugal;

M. Sieburg, Rheumatologische Facharztpraxis Magdeburg, Germany;

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

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

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

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

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

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

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

Scientific Advisory Committee:

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

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

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

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

Radiographic assessment:

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

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

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

Patient panel:

C. Rusthoven and M. Bakkers, The Netherlands

E. Frazão Mateus, and G. Mendes, Portugal

C. Elling-Audersch and D. Borucki, Germany

A. Cardone, Italy

P. Corduta and O. Constantinescu, Romania

P. Richards, United Kingdom

G. Aanerud, Norway

Disclosure of Interests

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

AB1210 FIBROMYALGIA AND BODY MASS COMPOSITION IN POST-MENOPAUSAL WOMEN: PRELIMINARY RESULTS FROM A CROSS-SECTIONAL MONOCENTRIC STUDY

Background

Fibromyalgia (FM) is characterized by chronic musculoskeletal widespread pain, fatigue, sleep disturbances and functional symptoms.

Objectives

Our study aimed to determine if FM could affect body composition of post-menopausal women and to investigated potential correlations between disease severity and body mass variables.

Methods

Thirty post-menopausal FM female patients (median age 58 years, BMI = 25.8) were diagnosed according to either ACR 1990 fibromyalgia classification criteria or ACR 2010 preliminary diagnostic criteria. They underwent Dual-energy X-ray absorptiometry (DEXA) for clinical purposes (i.e. screening for osteoporosis). The parameters analyzed by a dedicated software (GE Lunar, USA) were the spine and femoral bone mineral density (BMD), the total lean mass and the total body fat (TBF), quantitative variables of bone, muscle and fat composition. Additionally, qualitative analysis of the bone was indexed by the trabecular bone score (TBS). All the variables were compared with the parameters of 30 healthy controls (median age 59 years, BMI = 24.4) matched for sex and age. For each patient, data on disease duration, comorbidities, current treatment and disease severity self-reported scores were collected. The last ones derived from the Italian Fibromyalgia Impact Questionnaire Revised (FIQ-R) version that each patient independently compiled before the medical visit: widespread pain index (WPI), symptom severity scale (SSS), polysymptomatic distress scale (PDS), modified fibromyalgia assessment status (modFAS) and the FIQ-R total score.

Results

The clinical features of the FM patients included in our cohort are reported in Table 1. No statistically significant differences were observed between femoral/spine BMD, TBS and muscle mass between patients and controls (p = 0.3, p = 0.06, p = 0.16, p = 0.8 respectively). Conversely, both total and central body fat were significantly higher in patients compared with healthy controls (29.4 kg vs 25.2 kg, 15.7 kg vs 13.2 kg, p = 0.006 and p = 0.01 respectively). No significant correlations were observed between body mass composition indexes with scores of disease severity. Body mass composition variables did not statistically differ when patients were sub-analyzed according to pharmacological treatment and comorbidities.

Table 1.

Clinical features of FM patients included in present cohort (please see text for explanations of terminology)

Patients,N = 30Age (range)58.0 [53.8, 69.2]BMI (range)25.8 [23.0, 28.4]Disease duration (years), Median [IQR]4.5 [2.2, 9.2]ModFAS, Median [IQR]24.5 [20.0, 29.2]PDS, Median [IQR]17.5 [16.0, 23.2]SSS, Median [IQR]8.0 [6.0, 9.0]WPI, Median [IQR]12.0 [7.8, 15.0]FIQ-R, Median [IQR]57.9 [32.4, 68.8]Current pharmacological treatment Cyclobenzaprine N (%)24 (80) Fluoxetine N (%)5 (16.6) Duloxetine N (%)4 (13.3) Gabapentinoids N (%)2 (6.6) Tizanidine N (%)2 (6.6) Benzodiazepines N (%)2 (6.6) Cannabinoids N (%)3 (10)Nson-pharmacological treatmentAerobic physical activity N (%)5 (16)Comorbidities Hypertension N (%)10 (33.3) Diabetes N (%)3 (10) Osteoarthritis N (%)10 (33.3) Anxiety/depression N (%)3 (10) Psoriasis N (%)3 (10)

Conclusion

Our preliminary results suggest that FM seems not associated with impaired bone mass and bone quality in post-menopausal women compared to matched healthy controls, in line with the majority of literature evidences [1]. However, total and central adipose tissue mass resulted higher in this cohort of FM patients compared with controls but not correlate with disease severity. This might be due to a disease-induced sedentary lifestyle and might reinforce the concept that physical activity represents the best preventive method of overweight and obesity, one of most reported comorbidities for FM patients[2].

References

[1]Mateos F et al. Osteoporos Int. 2014;25(2):525-33.

[2]D’Onghia et al. Seminars in Arthritis and Rheumatism. 2021;51(2):409-24.

Disclosure of Interests

None declared

AB1351 FULL LONGITUDINAL NAILFOLD VIDEOCAPILLAROSCOPY ANALYSIS OF MICROVASCULAR CHANGES DURING NORMAL PREGNANCY

Background

During pregnancy profound physiologic changes are required to ensure fetal development and meet maternal needs. Microvascular remodelling is one major responsible for pregnancy haemodynamic adaptation, still it is not routinely evaluated in the obstetric field [1–2].

Objectives

To investigate the role of nailfold capillaroscopy (NCV) as a gold-standard and safe technique in detecting microvascular changes during normal pregnancy and to explore its possible application in clinical obstetric setting.

Methods

A population of 30 healthy pregnant women was longitudinally followed performing clinical assessment and NVC evaluation at each trimester and post-partum. Thirty non-pregnant age-matched healthy women having received at least two NVCs with a minimum 9 to 12-month interval were selected as controls. All NVC images were evaluated by a qualitative and semi-quantitative assessment using current standardised approach [3]. Statistical analyses were conducted to explore NVC parameters trend throughout gestation and its possible association with pregnancy course and clinical macrovascular parameters (i.e., systemic blood pressure, umbilical artery Doppler ultrasound).

Results

A progressive significant increase of capillary neoangiogenesis and a specular reduction in capillary dilations was observed during pregnancy (p<0.05). These statistically significant variations were not found in age-matched controls, who showed stable NVC parameters over a similar time frame (p<0.05). Not any significant association was found between NVC changes and pregnancy course, delivery outcome or macrovascular parameters.

Conclusion

This first comprehensive longitudinal NVC evaluation during normal pregnancy reports significant physiological microvascular variations throughout gestation, suggesting NVC as a safe and promising technique for further investigate and define patterns of microvascular changes in pregnant patients with rheumatic diseases.

References

[1]Thevissen et al. Expert Rev Med Devices. 2017;14(12):961–7.

[2]Abdo et al. Physiol Res 2014;63:395–408.

[3]Smith et al. Autoimmun Rev 2020; 19(3):102458.

Disclosure of Interests

None declared

POS1382 AN OVERVIEW OF NAILFOLD CAPILLAROSCOPY IN ITALY: RESULTS FROM A NATIONAL SURVEY

Background

In May 2020, the executive committee of the Italian Society of Rheumatology (SIR) endorsed the Italian study group (SG) on capillaroscopy and microcirculation in rheumatic diseases (CAPSIR) that first convened at the virtual annual meeting the same year. Nowadays capillaroscopy is a well-established, non-invasive technique with useful clinical applications in the assessment of connective tissue diseases (CTDs) [1] and mandatory for the differential diagnosis of Raynaud’s phenomenon (Rp) [2]. Despite growing interest in the use of this imaging technique in clinical and research settings, data on its current usage to assess microcirculation in rheumatic diseases in Italy are not available.

Objectives

To obtain an insight into the current utilization of capillaroscopy in the assessment of rheumatic patients in the Italian clinical setting.

This survey aimed: 1) to obtain an overview on the usage of capillaroscopy in rheumatological clinical practice in Italy, and 2) to gauge expert’s attitudes on factors influencing its use and the potential critical issues.

Methods

This online survey was devised to evaluate the opinions of the members of the SIR about nailfold capillaroscopy. It was designed with the contributions of the steering committee of CAPSIR SG, and emails with a link to the survey were sent to physicians affiliated with the SIR between July and August 2021 on behalf of the CAPSIR SG. At the beginning of the survey, the physician most experienced in capillaroscopy was asked to complete the questionnaire on behalf of his/her center. Questions were about the use of this technique in clinical practice and its critical issues. Data were reported with a descriptive analysis.

Results

One hundred and one centers, with at least one representative for each of the twenty Italian Region, completed the survey. 51.5% of respondents were in non-university hospitals, and 70 (69.3%) centers perform more than 100 capillaroscopy per year. The respondents were mainly practicing capillaroscopy for more than 5 years (85%) and gained certification of national or international dedicated training courses (84%). 43% of respondents had at least one scientific publication on this topic. Videocapillaroscope with 200X magnification was the most used instrument (91%). In public health services, the waiting time to schedule capillaroscopy is less than 3 months in 62.4% of centers. The survey has identified attitudes toward the use of capillaroscopy in the assessment and management of CTDs. In the screening phase of Rp, it is performed every 12 (mean value) months in patients with antinuclear antibodies (ANA) negative and every 6 months for those with positive ANA. Capillaroscopy is performed every 12 months (mean value) as part of the staging of CTDs (including systemic sclerosis). In more than 60% of centers, there is no specific diagnostic program for the screening of Rp and there is no connection with the general practitioners. 70% of the centers use capillaroscopy to follow the effect of therapies at least in systemic sclerosis.

Conclusion

At least one center for each Italian Region participated in this national survey, thus ensuring good geographical coverage. Moreover, the personnel who perform the exam had certified training and experience thus supporting the reliability of results. This survey indicates that the Italian public health system allows an acceptable waiting time to schedule the exam (less than 3 months). Italian Rheumatologists prescribe capillaroscopy as part of the clinical routine in the screening of Rp and as part of the annual checkup of CTDs. Critical issues remain the lack of a specific program and network with the general practitioners. To have a wider vision on this topic, our survey could be further extended to other European countries.

References

[1]Cutolo M, Smith V. Detection of microvascular changes in systemic sclerosis. and other rheumatic diseases. Nat Rev Rheumatol 2021;17(11):665-677.

[2]van den Hoogen F, Khanna D, et al. 2013 classification criteria for systemic sclerosis: an ACR/EULAR collaborative initiative. Ann Rheum Dis 2013;72(11):1747-55.

Disclosure of Interests

None declared

AB0738 Do cosmetic silicone implants trigger systemic sclerosis?

Background

The pathogenesis of systemic sclerosis (SSc) is thought to result from interactions between epigenetic features and environmental factors, leading to the onset and progression of the disease in genetically susceptible patients (1). Case reports of women with silicone breast implants who developed SSc have been published, but case-control and prospective studies in connective tissue diseases often failed to find an increased risk of SSc associated with silicone cosmetic surgery (2,3). These studies have several limitations, including heterogeneous cohorts of enrolled patients not selective for SSc, non-homogeneous disease duration or disease stage at study entry. For these reasons, the possible effect of silicone implants as immune adjuvants is highly suspected but remains unclear (4).

Objectives

Retrospective study of SSc patients, to find out who developed SSc after silicone cosmetic surgery.

Methods

The clinical files of 140 female patients with systemic sclerosis were retrospectively evaluated and clinical data collected.

Results

Five patients showing a history of silicone cosmetic surgery (3.6%) before SSc development were identified. The brief clinical histories of the five patients are below reported, showing very similar outcomes after silicone implant. 1. TC 47-year-old female underwent cosmetic breast prosthesis: twelve months later she experienced Raynaud’s phenomenon (RP) and diffuse cutaneous SSc after 10 further months; antinuclear antibodies were positive with a speckled and nucleolar pattern, but specific SSc-related autoantibodies negative. 2. LS 28-year-old female underwent cosmetic breast prosthesis: twenty-two months later RP appeared and anticentromere antibodies (ACA) positive aggressive diffuse SSc was diagnosed one year later. 3. PJ 38-year-old female underwent cosmetic breast prosthesis: eleven months later she experienced RP and after 10 further months, aggressive diffuse cutaneous SSc; antinuclear antibodies were positive with a speckled patter, but specific SSc-related autoantibodies were negative. 4. CM 58-year-old female who underwent cosmetic lip silicone application: one year later she complained of simultaneous onset of RP and very aggressive diffuse cutaneous SSc with anti-topoisomerase positivity; she died during follow-up. 5. BS 33-year-old female who underwent cosmetic breast prosthesis: twenty months later she complained of RP and after ten further months, limited cutaneous SSc with ACA positivity; SSc clinical condition partially improved and its progression stopped after prosthesis removal. Globally, after silicone implant, RP occurred in a mean time of 15±5 months and SSc in 23±8 months.

Conclusion

This study reports a prevalence of 3.6% of silicone cosmetic surgery before SSc onset, interestingly with a close and similar temporal association between silicone implant and disease development. This finding suggests a possible role of silicone in SSc pathogenesis (ASIA syndrome). Specifically addressed large clinical studies or big-data studies need to rule out this matter.

References

[1]Denton C, et al. Lancet 2017; 390: 1685–99.

[2]Marie I et al. Semin Immunopathol 2015; 37:463–473.

[3]Coroneos CJ et al. Ann Surg. 2019 Jan;269(1):30-36.

[4]Watad A et al. Lupus. 2017; 26:675-681.

Disclosure of Interests

Adriano Lercara: None declared, Alberto Sulli: None declared, Carmen Pizzorni: None declared, Emanuele Gotelli: None declared, Sabrina Paolino: None declared, ANDREA CERE: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Celgene, Pfizer, Boehringer-Ingelheim

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

Background

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

Objectives

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

Methods

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

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

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

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

Results

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

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

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

Table 1.

Adrenal insufficiency signs and symptoms.

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

* Systolic RR < 90 or diastolic RR < 60.

**Mean (SD)

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

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

Conclusion

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

References

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

Acknowledgements

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

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

Disclosure of Interests

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

AB0675 Health related quality of life in patients with mixed connective tissue disease: A comparison with matched systemic sclerosis patients

Background

Mixed connective tissue disease (MCTD) is a systemic auto-immune disorder, being probably the least common among the connective tissue diseases. Symptoms can be severe and could affect health-related quality of life (HRQoL). Identification of the burden of MCTD patients is of key importance to provide appropriate pharmacological and non-pharmacological care. No reports on HRQoL have been published in adult patients with MCTD.

Objectives

To perform an explorative study to evaluate HRQoL and its main determinants in MCTD patients, and compare HRQoL between MCTD and matched systemic sclerosis (SSc) patients.

Methods

MCTD patients fulfilling the Kahn criteria and participating in the MCTD prospective follow-up cohort of the Leiden University Medical Center were included. In addition, SSc patients matched for age, gender and disease duration were included for comparison. Data on disease characteristics, functional disability and HRQoL were collected annually for both disease groups. HRQoL was evaluated using the 36-Item Short Form Health Survey (SF36) and EuroQol (EQ5D). At baseline, HRQoL, as reflected by SF36 mental component score (MCS), SF 36 physical component score (PCS) and EQ5D were compared between MCTD and SSc patients. For MCTD patients, factors associated with HRQoL at baseline were identified using linear regression and change in HRQoL over 3 years was evaluated using linear mixed models. In addition, characteristics of MCTD patients who showed worsening of MCS and/or had PCS superior to the minimal clinical important difference of three points were identified.

Results

Thirty-four MCTD patients (121 visits; 82% female, mean age 42 years, median disease duration 45 months) and 102 SSc patients (424 visits; 82% female, mean age 45 years, median disease duration 49 months) were included. At baseline, MCTD-patients more often had ILD (47% vs. 34%, p=0.027), cardiac involvement (30% vs. 2%, p<0.001), synovitis (26% vs. 11%, p=0.004) and myositis (15% vs. 1%, p=0.001) compared to SSc patients, whereas SSc patients more often used immunosuppressive treatments except for hydroxychloroquine (MCTD:18% vs. SSc:7%, p=0.007).

Baseline HRQoL in MCTD was comparable to HRQoL in SSc, with mean SF36-PCS of 40.2 (SD:9.1) and mean SF36-MCS of 44.9 (SD:9.9), which is (nearly) one standard deviation lower than the general Dutch population. The SF36 subscore “general health perception” was the most impacted in both groups (MCTD: 38.5 [SD:7.0], SSc: 39.9 [SD:8.9]). The median EQ5DNL was 0.38 (IQR:0.14 – 0.54) and comparable between SSc and MCTD.

At baseline, in MCTD, ILD was significantly associated with SF36-PCS (β:6.98, 95% CI: 1.10 to 12.86) and SF36-MCS (β:-8.10, 95% CI:-14.93 to -1.26). Sclerodactyly was significantly associated with EQ5DNL (β:0.006; 95% CI:0.002 to 0.010) and SF36-PCS (β:0.12, 95% CI:0.03 to 0.21). No other significant associations were identified.

Over time, in MCTD, both the SF36-MCS and SF36-PCS improved significantly (MCS: β:2.35/year [95% CI:0.58 to 4.13], PCS: β:1.34/year [95% CI:0.03 to 2.65), whereas EQ5DNL was stable. Explorative analyses did not reveal a specific clinical characteristic with significant impact on the change of HRQoL over time. With an MCID of 3 points on the MCS and PCS, 7 MCTD-patients worsened on the MCS and 3 on the PCS. Patients who showed worsening of MCS over time tended to be older, more often had ILD, sclerodactyly and GI complaints, and had worse exercise tolerance. All these differences did not reach statistical significance. The patients who decreased PCS more often had ILD (100% vs. 41%, p=0.015), and used glucocorticoids more often (33% vs. 0%, p=0.046), were slightly older and had a worse exercise tolerance as compared to those who showed a stable/improving PCS over time.

Conclusion

Like in SSc, HRQoL is significantly impaired in MCTD, especially the general health perception of patients. Cardiac involvement, ILD, age and worse functional disability might specifically impact HRQoL in MCTD. However, these associations need further evaluations in larger cohorts.

Disclosure of Interests

None declared

AB1370 MICROVASCULAR CAPILLAROSCOPIC ABNORMALITIES AND AUTOANTIBODY OCCURRENCE IN SARCOIDOSIS PATIENTS

Background

Sarcoidosis (S) is a granulomatous disease with multi-organ involvement displaying a mixed immune-mediated pathophysiology. Raynaud’s phenomenon (RP) has been occasionally reported in S patients [1] and serum positivity for autoantibodies has been detected in S patients but their significance is debated [2].

Objectives

We described nailfold videocapillaroscopy (NVC) findings and estimated the prevalence of serum anti-nuclear (ANA) and extractable nuclear antigen autoantibodies (ENA-Abs) in S patients, comparing them with age- and sex- matched healthy controls (HCs) and patients with primary Raynaud’s phenomenon (PRP). Secondarily, we analysed potential correlations between NVC findings with the occurrence of autoantibodies, immunomodulatory treatment, laboratory parameters, variables of pulmonary function and whole-body imaging.

Methods

Twenty-seven (27) S patients, classified according to WASOG criteria[3], were assessed through NVC examination, laboratory parameters (including serum concentrations of angiotensin-converting enzyme [ACE], C-reactive protein [CRP], calcium, phosphorus, albumin, 25-hydroxyvitamin D, parathormone, ANA and ENA), pulmonary function tests (PFTs), chest-X ray and positron emission tomography/computerized tomography (PET/CT).

Among NVC parameters, we analysed capillary dilations, giant capillaries, haemorrhages, nonspecific abnormalities, and capillary absolute number for mm [4].

Pulmonary involvement was classified by X-ray Scadding staging system (SSS) scoring S patients in 4 grades [5]. From PET data, the maximum standard uptake value (SUVmax) was quantified as a variable of tissue 18-fluorodeoxyglucose hyper-uptake: consequently, S patients were defined PET-positive when SUV value ≥ 2.5. NVC parameters and ANA/ENA dosage were recorded also in 30 PRPs and 30 HCs.

Results

We excluded, among the cohort of S patient, one participant having a systemic sclerosis in overlap with S. The remaining 26 S patients (mean age 56.5 ± 12.5 years, 53.8 % of females, disease duration 28.4 ± 55.1 months, 27% glucocorticoid-naïve) showed a significant higher rate of dilations and nonspecific abnormalities and a lower mean capillary absolute number than PRPs and HCs (p < 0.01 for all comparisons). (Figure 1)

The prevalence of ANA positivity was significantly higher in S patients compared with PRPs and HCs (p < 0.02 for both). Among the whole cohort of patients only one S patient displayed a positive ENA-Ab (Ro52).

In the analysis of S patients’ subgroup, a significant negative correlation was detected between serum ACE levels with the presence of capillary dilations (rho = -0.45, p = 0.04), between CRP and mean capillary absolute number (rho = -0.49, p = 0.02) and a positive correlation was also detected between the mean capillary absolute number and the forced vital capacity percentage (FVC%) (rho = 0.40, p = 0.04).

Conclusion

Our findings suggest a microvascular involvement in sarcoidosis whose investigation by NVC could be useful for the detection of an overlapping connective tissue disease and for the monitoring of the phenotypes of S patients displaying RP.

The positivity for autoantibodies in S patients is in line with literature data suggesting, at least partially, autoimmune features of the disease or the production of autoantibodies reactive to tissue damage.

The correlations between NVC findings with ACE levels and lung function variables generate hypotheses of a potential partial vascular impairment in sarcoidosis disease activity and lung involvement.

References

[1]Nigro A et al. Reumatismo 2004; 56: 278-81.

[2]Kobak S et al. Autoimmune Diseases 2014

[3]Judson M.A et al. Clin Rev Allergy Immunol 2015; 49: 63-78.

[4]Smith V et al. Autoimmun Rev 2020; 19: 102458.

[5]Scadding J.G. Br Med J 1961; 2: 1165-72.

Disclosure of Interests

None declared

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

Background

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

Objectives

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

Methods

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

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

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

Results

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

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

Conclusion

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

References

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

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

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

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

Acknowledgements

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

Disclosure of Interests

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

AB0739 Aminaphtone tolerability and safety in scleroderma patients: a four-year follow-up

Background

Recent studies show that Aminaphtone is effective in the treatment of Raynaud’s phenomenon (RP) symptoms in patients with systemic sclerosis (SSc), and an increase in peripheral blood perfusion was demonstrated by Laser speckle contrast analysis in treated patients (1,2). Unfortunately, the drug is only available in a few countries.

Objectives

To evaluate long-term tolerability and safety of Aminaphtone in SSc patients with secondary RP.

Methods

Seventy SSc patients (EULAR/ACR criteria) (mean disease duration 8±7 years, mean age 61±10 years) who started Aminaphtone treatment due to active RP were enrolled and followed for at least 4 years. Patients were also taking various concomitant treatments, including immunomodulators, cyclic intravenous iloprost, endothelin receptor antagonists and aspirin. None was taking sildenafil or selexipag. Survival of Aminaphtone in therapy was assessed along with possible drug-related side effect. The Raynaud condition score (RCS) to asses disease severity and blood examinations were routinely performed.

Results

The mean follow-up of patients was 49±11 months. Aminaphtone was orally administered at 75 mg twice daily, as standard initial posology in our clinical practice. During the follow-up, six patients (8,6%) referred headache as side effect and had to reduce Aminaphtone posology to 75 mg per day, while maintaining clinical benefits. No other side effect related to the drug was observed during the follow-up. Seven patients increased the posology to 75 mg three times daily due to poor effectiveness, and further seven patients increased the posology to 75 mg three times daily only during the colder months of the year. Conversely, thirty-five patients reduced the dosage to 75 mg once daily only during the hottest months of the year, due to partial remission of the RP. During follow-up, blood tests did not reveal any significant alteration ascribable to Aminaphtone. A subjective improvement of Raynaud’s symptoms (assessed by the RCS) was already evident after 1-2 months of treatment in fifty-six patients (80%). Globally, the patients referred a sustained improvement followed by stabilization of Raynaud’s symptoms during the follow-up.

Conclusion

During an average observation period of four years, Aminaphtone showed a good tolerability and safety profile along with sustained efficacy in patients with SSc-related RP, without disabling or serious side effects. A randomized controlled trial for Aminaphtone use in the management of SSc-related RP is desirable to better assess the clinical efficacy of the drug over time.

References

[1]Parisi S, et al. Am J Int Med. 2015;3:204–209. 2. Ruaro B et al. 2019. Front Pharmacol 10:293.

Disclosure of Interests

ANDREA CERE: None declared, Emanuele Gotelli: None declared, Adriano Lercara: None declared, Carmen Pizzorni: None declared, Sabrina Paolino: None declared, Elisa Alessandri: None declared, Maurizio Cutolo Grant/research support from: Bristol Myers Squibb, Celgene, Pfizer, Boehringer Ingelheim, Alberto Sulli: None declared

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

Background

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

Objectives

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

Methods

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

Table 1.

Predictor sets.

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

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

Results

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

Conclusion

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

References

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

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

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

Acknowledgements

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

Disclosure of Interests

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

P190 CAROTID DOPPLER ULTRASONOGRAPHIC AND DAPAGLIFOZIN IN TYPE 2 DIABETIC PATIENTS

Background

Carotid Doppler ultrasonography (USG) is widely used to measure haemodynamic parameters, such as Intima–Media Thickness (IMT) and blood flow velocities (i.e. Peak–Systolic Velocity [PSV], End–Diastolic Velocity [EDV], and Resistive Index [RI]). Dapaglifozin (SGLT2i) have been shown to reduce the risk of cardiovascular disease in type 2 diabetes (T2DM) patients. SGLT2i is a sodium–glucose co–transporter 2 inhibitor that reduces renal glucose reabsorption, thus increasing urinary glucose excretion. This leads to sustained systolic and diastolic blood pressure reduction, through natriuresis. We hypothesized that this agent would also reduce arterial stiffness.

Aim

The purpose of this study was to evaluate cardiovascular disease risk indirectly through USG of carotid artery vascular markers in T2DM patients using dapagliflozin.

Methods and Results

40 patients presenting to our clinic between march 2019 and march 2021 and diagnosed with T2DM were included in the study. These were divided into two groups : 1) a dapagliflozin group of 20 patients and 2) 20 patients non–dapagliflozin control group. Velocity parameters were: peak–systolic velocity (PSV), end–diastolic velocity (EDV), pulsatility index (PI), resistive index (RI). Examination was performed on distal portion of CCA, and we took the mean of both CCA. The mean duration of follow–up was 2.0 years. Mean ages were 55 ± 10 years in the dapagliflozin group and 50 ± 10 in the control group. Common carotid artery, PSV, and EDV parameters were higher while RI was lower (p ˂ 0.01), in the dapagliflozin group than in the control group. Vascular resistance was lower in the group using dapagliflozin for diabetes management. In addition In the dapagliflozin group, the IMT decreased after dapagliflozin therapy (P &lt; 0.01).

Conclusions

haemodynamic parameters were better performing in the group using dapagliflozin for diabetes management. Finally SGLT2i can decrease the IMT in patients with T2DM, which is closely related to cardiovascular benefit in patients with T2DM.

POS0882 AMINAPHTONE LONG-TERM TREATMENT IN SYSTEMIC SCLEROSIS

Background:

Aminaphtone has been used since many years to treat microvascular disorders. Aminaphtone seems to improve clinical symptoms of Raynaud’s phenomenon (RP), either primary or secondary to systemic sclerosis (SSc) by increasing peripheral blood perfusion as assessed by Laser speckle contrast analysis (1).

Objectives:

To evaluate long-term survival and tolerability of Aminaphtone in SSc patients with secondary RP.

Methods:

Eighty SSc patients (mean age 64±12 years; mean disease duration 9±8 years) treated with Aminaphtone due to active RP were enrolled (ACR/EULAR 2013 criteria). Patients were taking also various concomitant treatments, including aspirin, cyclic intravenous iloprost, immunomodulators, endothelin receptor antagonists. SSc patients performed periodic clinical and laboratory assessments on average every four months per our clinical practice. Duration of Aminaphtone administration, side effects, and self-assessment of Raynaud Condition Score (RCS) with a scale from 0 (absence of pain) to 10 (maximal pain) were retrospectively assessed.

Results:

The observation period was between twelve and seventy months (mean 36±19 months). Aminaphtone was administered at 75 mg twice daily, as standard initial posology per our clinical practice. During the follow-up, five patients (6.2%) referred headache as side effect: three of them had to reduce Aminaphtone posology to 75 mg per day, while maintaining clinical benefits; two patients had to stop the treatment. No other side effects related to the drug appeared during the treatment period, and repeated blood tests did not reveal any significant alteration ascribable to Aminaphtone. After 3 months of treatment sixty-six patients (83%) referred a subjective improvement of RP (RCS 3.6±0.8, vs baseline RCS 7.4±0.8, p=0.032), whereas fourteen patients (17%) were clinically unsatisfied (RCS 6.1±0.4, p=0.12). In this last group of patients, Aminaphtone posology was increased to 75 mg three times a day with a satisfactory amelioration in further nine patients (94% of total) (RCS 4.0±0.6, p=0.04), while five patients (6.2%) definitively discontinued therapy for subjective ineffectiveness within six months. Patients referred a sustained improvement of RCS along the observational period (36±19 months) (last RCS 3.6±0.7 vs baseline, p=0.031).

Conclusion:

During an average observation period of three years, Aminaphtone showed a good tolerability profile along with sustained efficacy in 94% of patients with SSc-related RP, without disabling side effects. The absence of a placebo-control group, the retrospective design limit the results, and a randomized controlled trial for Aminaphtone use in the management of SSc-related RP is needed.

References:

[1]Ruaro B et al. 2019. Front Pharmacol 10:293.

Disclosure of Interests:

Alberto Sulli: None declared, Emanuele Gotelli: None declared, ANDREA CERE: None declared, Elvis Hysa: None declared, Greta Pacini: None declared, Carmen Pizzorni: None declared, Sabrina Paolino: None declared, Maurizio Cutolo Grant/research support from: Laboratori Baldacci s.p.a.

POS0330 NINTEDANIB (TYROSINE KINASE INHIBITOR) DOWNREGULATES THE TRANSITION OF CULTURED SYSTEMIC SCLEROSIS FIBROCYTES INTO MYOFIBROBLASTS AND THEIR PRO-FIBROTIC ACTIVITY

Background:

Fibroblast-to-myofibroblast transition is one of the fundamental steps involved in the fibrotic process that characterise systemic sclerosis (SSc) [1]. Myofibroblasts are α-smooth muscle actin (αSMA) positive cells that contribute to fibrosis through the excessive synthesis and deposition of extracellular matrix (ECM) proteins, primarily fibronectin (FN) and type I collagen (COL1) [2].

Among the cells involved in the fibrotic process of SSc, circulating fibrocytes seem to have an emerging role as an important source of fibroblasts and myofibroblasts [3].

Nintedanib is a tyrosine kinase inhibitor approved for the treatment of idiopathic pulmonary fibrosis that interferes with the signalling pathways involved in the pathogenesis of fibrosis (4). Nintedanib was recently demonstrated to have a beneficial effect in patients with interstitial lung disease (ILD) associated with SSc (5).

Objectives:

To investigate nintedanib effect in inhibiting the in vitro transition of circulating SSc fibrocytes into myofibroblasts and their pro-fibrotic activity.

Methods:

Circulating fibrocytes were obtained from 14 SSc patients (mean age 64±14 years), who fulfilled the 2013 ACR/EULAR criteria for SSc and that underwent complete disease staging in a day-hospital setting at the Rheumatology Division of Genoa University. Five age-matched healthy subjects (HSs) were also analysed. All SSc patients and HSs signed the informed consent and the local EC approved the study. Peripheral blood mononuclear cells were isolated by density gradient centrifugation and plated on FN-coated dishes. After overnight culture, non-adherent cells were removed, and adherent cells were maintained in growth medium for 8 days (T8) to obtain fibrocytes [6]. T8-cultured SSc fibrocytes were maintained in growth medium (untreated cells) or treated with nintedanib 0.1μM and 1μM for 3 and 24 hours. Fibroblast specific protein-1 (S100A4) and αSMA, as markers of fibroblast/myofibroblast phenotype, together with COL1 and FN, were investigated by qRT-PCR and Western blotting. Non-parametric Mann-Whitney and Wilcoxon tests were used for the statistical analysis.

Results:

Significantly elevated gene and protein expressions of αSMA, S100A4, COL1 and FN were observed in SSc fibrocytes compared to HS fibrocytes (gene: αSMA p<0.001; others p<0.0001; protein: all p<0.05). In accordance with the antibody positivity for Scl70 and the presence or absence of ILD at CT scan, SSc patients were grouped as either Scl70 positive patients with ILD (Scl70+ILD+) or Scl70 negative patients without ILD (Scl70-ILD-). Significant αSMA, S100A4, COL1 and FN gene expressions were found in fibrocytes from Scl70+ILD+ compared to HS fibrocytes (αSMA p<0.001; others p<0.0001). Moreover, fibrocytes from Scl70+ILD+patients showed a more significant gene expression of fibroblasts/myofibroblasts markers compared to Scl70-ILD-patients (p<0.01 for S100A4), whereas no differences were observed for ECM gene expression.

Nintedanib reduced the gene and protein expression of αSMA, COL1 and FN in SSc fibrocytes compared to untreated ones with different statistical significance.

Noteworthy, nintedanib significantly downregulated αSMA, S100A4, COL1 and FN gene expression (all p<0.05) in Scl70+ILD+fibrocytes, whereas only that of S100A4 and FN was significantly downregulated (p<0.05) in Scl70-ILD- fibrocytes compared to untreated cells.

Conclusion:

Nintedanib seems to downregulate in vitro the transition of fibrocytes into myofibroblasts and their pro-fibrotic activity, particularly in cells isolated from Scl70+ILD+SSc patients.

References:

[1]Cutolo M et al. Exp Rev Clin Immunol. 2019;15:753-64.

[2]Van Caam A et al. Front. Immunol. 2018;9:2452.doi:10.3389/fimmu.2018.02452.

[3]Distler JH et al. Arthritis Rheumatol. 2017;69:257-67.

[4]Distler O et al. New Eng J Med. 2019; 380:2518-28.

[5]Maher TB et al. Arthritis Rheumatol.2020.doi:10.1002/art.41576.

[6]Cutolo M et al. Arthritis Res Ther. 2018;20:157.doi:10.1186/s13075-018-1652-6.

Acknowledgements:

We thank Stefano-Lutz Willing for the scientific support through the study.

Disclosure of Interests:

Stefano Soldano: None declared, Paola Montagna: None declared, Emanuele Gotelli: None declared, Samuele Tardito: None declared, Sabrina Paolino: None declared, Claudio Corallo: None declared, Carmen Pizzorni: None declared, Alberto Sulli: None declared, Carlotta Schenone: None declared, Greta Pacini: None declared, Vanessa Smith: None declared, Maurizio Cutolo Grant/research support from: I received grant/research support from Bristol-Myers Squibb, Boehringer, Celgene

POS0850 NAILFOLD CAPILLARY DILATIONS IN RAYNAUD’S PHENOMENON: QUANTIFYING A PREDICTIVE THRESHOLD FOR THE ‘SCLERODERMA PATTERN’

Background:

Non-specific abnormalities could be detected by nailfold videocapillaroscopy (NVC) in subject with primary Raynaud’s Phenomenon (RP) several years before the clinical onset of connective tissue diseases (CTD)s [1]. Previous findings from our group proved that ≤30 μm capillary dilations in RP patients have a negative predictive value for developing the ‘scleroderma pattern’ during follow-up [2].

Objectives:

To investigate the role of NVC >30 μm capillary dilations as positive predictive factors of the ‘scleroderma pattern’ in RP patients later developing systemic sclerosis (SSc)-related RP.

Methods:

A 10-year retrospective NVC-based investigation evaluated the dataset of sequential NVCs of 18 RP patients later developing SSc (cases) and 19 sex- and age-matched RP patients later developing other CTDs (controls). Both cases and controls had ≥1 NVC performed before the ‘scleroderma pattern’/CTD diagnosis (basal NVC) showing >30 μm dilated capillaries. Each NVC was qualitatively and semi-quantitatively assessed, recording number of total capillaries, number and average/site-specific diameters (arterial, apical, venous) of >30 μm dilated capillaries [3]. Statistical analysis was performed to stratify the risk of developing the ‘scleroderma pattern’.

Results:

Significant differences of capillary diameters were observed between cases and controls both at basal NVC and during follow-up (p<0.001). The proportion of >30 μm dilated capillaries in basal NVC was the strongest predictor of ‘scleroderma pattern’ in a median 3-year time, with a 27% cut-off (PPV 0.79, 95%CI 0.54,0.94; p<0.001). Additional “Higher risk” NVC hallmarks for ‘scleroderma pattern’ development were apical diameter >40 μm (p<0.001), venous diameter >25 µm (p<0.05) and average diameter ≥35 µm (p<0.005). Conversely, CTDs patients showed a stable NVC ‘non-scleroderma pattern’ over a median 10-year time.

Conclusion:

This is the first study to show that NVC-detected homogeneous and progressive capillary loop dilations in RP patients significantly contribute to predict the ‘scleroderma pattern’ evolution within a median 3-year time, possibly providing a “very early” window of opportunity in SSc pre-clinical stages.

References:

[1]Cutolo M et al. Expert Rev Clin Immunol. 2019;15(7):753–64. [2] Trombetta AC et al. J Rheumatol 2016;43:599–606. [3] Smith et al. Autoimmun Rev 2020; 19(3):102458.

Disclosure of Interests:

None declared

POS1250 VITAMIN D DEFICIENCY IS MAINLY ASSOCIATED WITH SEVERE LUNG INVOLVEMENT, LONGER DISEASE DURATION AND RISK OF DEATH IN ELDERLY COVID-19 PATIENTS

Background:

Vitamin D regulates the innate and adaptive immune system responses and low vitamin D levels have been associated with the increased risk of respiratory tract infections (1). Vitamin D deficiency has been recently reported to interfere with the prognosis of COVID-19 (2,3).

Objectives:

The aim of this study was to correlate the 25OH-vitamin D serum levels with lung involvement and disease severity, in a cohort of elderly patients hospitalized for SARS-CoV-2 infection.

Methods:

Sixty-five COVID-19 patients (mean age 76±13 years) and sixty-five sex- and age-matched control subjects (CNT) were included in the study. Respiratory parameters (PaO2, SO2, PaCO2, PaO2/FiO2), clinical and laboratory parameters (including 25OH-vitamin D, D-dimer, C-reactive protein) and type of radiological pulmonary involvement were collected at hospital admission. Statistical analysis was performed by non-parametric tests.

Results:

Vitamin D sufficiency (>30 ng/ml), insufficiency (between 20 and 30 ng/ml), deficiency (between 10 and 20 ng/ml) and severe deficiency (<10 ng/ml) were observed respectively in 11, 11, 21 and 57 % of COVID-19 patients. Vitamin D serum levels were found significantly lower in COVID-19 patients than in CNT (median 8 vs 16 ng/ml, p=0.001). A statistically significant positive correlation was observed between vitamin D serum levels and SO2 (p=0.05), PaO2 (p=0.03), PaO2/FiO2 (p=0.02). A statistically significant negative correlation was found between vitamin D serum levels and severity of radiologic pulmonary involvement: vitamin D was significantly lower in COVID-19 patients with either diffuse/severe interstitial lung involvement (p=0.05) or multiple lung consolidations (p=0.0001) than in those with mild radiological lung involvement. Significantly lower vitamin D serum levels were found in COVID-19 patients who died during hospitalization, compared to those who survived (median 3 vs 8 ng/ml, p=0.05). Finally, a statistically significant negative correlation was found between vitamin D serum levels and D-dimer (p=0.04), C-reactive protein (p=0.04) and disease duration (p=0.05).

Conclusion:

This study confirms that severe vitamin D deficiency is associated with more severe lung involvement, longer disease duration and risk of death in elderly COVID-19 patients.

References:

[1]Cutolo M, et al. RMD Open. 2020; 6(3):e001454.

[2]Bilezikian JP, et al. Eur J Endocrinol. 2020; 183(5):R133-R147.

[3]Weir EK, et al. Clin Med (Lond). 2020; 20:e107-e108.

Disclosure of Interests:

None declared

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

Background:

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

References:

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

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

Table 1.

Comorbidities and concomitant medications at baseline in the GLORIA trial.

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

Acknowledgements:

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

Disclosure of Interests:

None declared

POS0583 ENGINEERED GLOVE TO EVALUATE THE SPEED OF THE HANDS’ MOVEMENTS IN RHEUMATOID ARTHRITIS

Background:

Rheumatoid arthritis (RA) is a long-term, progressive, and disabling autoimmune disease1. The disease activity can be quantified by the Disease Activity Score 28-joint count – C reactive protein (DAS28crp)2; the evaluation of disability function (DF) is actually mainly performed only by subjective Patient Reported Outcomes (PROs) like Health Assessment Questionnaire (HAQ)3; to investigate the functional aspects of RA hands it is usually used the grip strength (GS)4. However, in the scientific literature no tool, which objectively evaluates movement speed, has been reported. The Hand Test System (HTS, ETT) is an engineered glove (RAGLOVE), nowadays applied for neuroscience studies to evaluate hand motility5

Objectives:

To objectively evaluate the RA hand’s speed of the fine movements, through the HTS and to compared with a group of age and sex matched healthy controls. To verify the correspondence with the HAQ, DAS28, GS.

Methods:

55 consecutives RA patients (pts) (6 males, age 61 ± 16 years, mean duration of disease 12 ± 8 years), classified according to 2010 ACR/EULAR criteria6, and 50 matched healthy controls (HCs) were enrolled. After consent, all participants undergone HTS test that recognizes the touches between the finger tips during the opposition movements of the hands in standard sequences of movements, after dressed the glove. A multiple finger evaluation (MFE) and a single finger evaluation (SFE) were performed using a dedicated software that provided the physician the following quantitative parameters: Touch Duration (TD), Inter Tapping Interval (ITI) and Movement Rate (MR). Average time for hand 2 minutes. RA pts compiled the HAQ, performed the GS and a DAS28cpr was performed.

The student’s t-test was used to compare the glove’s parameters between the groups whereas the analysis of variance (ANOVA) was utilized to verify potential differences between the populations. In order to evaluate the single correlations, the r and p values of Pearson were employed.

Results:

For MFE, glove parameters TD and ITI were significantly higher in RA pts than HCs, whereas; MR was significantly lower in RA pts compared to HCs (all p <0.001).

For SFE non-affected fingers (not swollen and not tender) of RA pts performed better than a clinically affected fingers, but in any case significantly worse than average HCs fingers (p < 0.001).

There is a statistically significant correlation between the GS and MR (r= 0.39 p=0.003) and TD (r=-0.33 p=0.015).

TD, ITI e MR of RA pts showed a significant correlation with the total score of the HAQ (r = 0.56, r = 0.39, r = -0.56, all p < 0.001;). DAS28, considered as a continuous variable, proved to be significantly correlated with the TD (r = 0.36, p = 0.009). When the RA patients were grouped according to the disease activity by DAS28cpr7, there was an increase of one third of the TD’s logarithm for each increase in the activity class (linear regression with ordinal predictors, beta = 0.33; 95%CI 0.03, 0.63,p < 0.0297). Finally, even RA pts in remission showed a TD significantly higher compared with HCs (p= 0.034).

Conclusion:

The RAGLOVE is shown as a new safe and fast tool to evaluate a new objective parameter in the hand’s functionality: the speed of finger movements. In RA pts, an inversely proportional correlation emerges between the speed of movement and disease activity.

The significant correlation found with HAQ, highlights the loss of motility of the hands as one of the main determinant of disability. The RAGLOVE is now tested in RA patients undergoing treatment.

References:

[1]Hakkinen et al Ann Rheum Dis. 2005;

[2]Van Der Heijde et al J of Rheum. 1993;

[3]Fries et al Arthritis Rheum. 1980;

[4]Mathiowetz et al J Hand Surg Am. 1984;

[5]Carmisciano et al Eur J Neurol. 2020;

[6]Aletaha et al. Ann Rheum Dis. 2010;

[7]Aletaha et al Arthritis Rheum 2005.

Disclosure of Interests:

None declared

AB0354 FDG-PET-DETECTED LARGE VESSEL VASCULITIS DOES NOT PREDICT DISEASE OUTCOME IN PATIENTS WITH GIANT CELL ARTERITIS AND POLYMYALGIA RHEUMATICA

Background:

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are tightly associated inflammatory conditions of the elderly [1]. Both disorders can exhibit an increased articular and vascular uptake of 18-fluorodeoxyglucose (18-FDG) at positron emission tomography (PET)/computed tomography (CT) scan [2].

Objectives:

This study evaluated if large-vessel vasculitis (LVV) detected by PET/CT in patients with PMR and/or cranial GCA had a negative prognostic value.

Methods:

108 patients (35 men and 73 women) with a median age of 74 years (range 50-92 years) were prospectively enrolled in our centre over 4 years. PMR was diagnosed by Bird et al. criteria and GCA by the ACR criteria. Six patients died shortly after the first visit (V0) and six were lost at follow-up. Of the remaining 96 patients, 77 were classified as PMR, 6 as GCA and 13 were affected by both diseases.

At V0, patients underwent a clinical, laboratory and PET/CT evaluation, and were stratified according to the presence or not of LVV. Follow-up visits were performed every 6 months for a median of 40 months. Disease outcomes were: prednisone (PDN) use and its cumulative dosage, need of methotrexate (MTX), number of relapses, patients’ death, and PMR disease activity score (PMR-DAS). The independent variables were age, sex, disease duration, fever, C-reactive protein (CRP) concentration, platelet count (PLT), presence of cranial GCA, degree of joint and vascular uptake of FDG, and presence of LVV. The predictive role of LVV was tested by multiple regression.

Results:

LVV was seen in 47 patients (49 %), 31 with PMR, 6 with GCA and 10 with both diseases. Patients with or without LVV did not significantly differ in terms of demographic and laboratory parameters except for a non-significant higher number of PLT in patients with LVV. Clinical and laboratory parameters at V0, stratified per disease and considered together, did not significantly change between PET+ and PET- patients (table 1). Lastly, none of the independent variables, including LVV, could predict disease outcomes.

Conclusion:

The presence of a PET-detected LVV at diagnosis does not seem a negative prognostic factor in PMR and GCA. As a consequence, routine investigation by PET/CT of patients with PMR and GCA is not indicated to predict disease outcome.

References:

[1]Dejaco C, Duftner C, Buttgereit F, Matteson EL, Dasgupta B. The spectrum of giant cell arteritis and polymyalgia rheumatica: revisiting the concept of the disease. Rheumatology (Oxford). 2017 Apr 1;56(4):506-515. doi: 10.1093/rheumatology/kew273. PMID: 27481272.

[2]Blockmans D, Coudyzer W, Vanderschueren S, Stroobants S, Loeckx D, Heye S et al. Relationship between fluorodeoxyglucose uptake in the large vessels and late aortic diameter in giant cell arteritis. Rheumatology (Oxford). 2008 Aug;47(8):1179-84. doi: 10.1093/rheumatology/ken119. Epub 2008 May 31. PMID: 18515868.

Table 1.

Clinical, laboratory and imaging features between PET+ and PET- patients at V0

Features at V0PET+ patientsPET- patientspMorning stiffness (min)30 (0-480)60 (0-360)0.20Haemoglobin (g/dL)12.3±1.512.6±1.50.28Platelets (x 103/mm3)349 (108-643)297(159-571)0.08C-reactive protein (mg/dL)35.5 (3.4-149)36.2 (2-149)0.54Erythrocyte sedimentation rate (mm/h)62.5 (10-120)57.5 (10-120)0.29Total Vascular Score at PET20 (4-41)6 (0-12)0Total Joint Score at PET18 (5-30)18 (5-32)0.77

Disclosure of Interests:

None declared

OP0310 GENDER AND FIBROMYALGIA SEVERITY: REAL LIFE DATA FROM THE ITALIAN REGISTRY

Background:

Fibromyalgia (FM) patients report chronic widespread pain, fatigue, cognitive difficulties and sleep disturbances, often associated with anxiety and/or depression (1). FM syndrome more frequently affects women and many papers describe gender-related differences in the perception, description and expression of pain (2), but up to now, the impact of gender on the clinical severity of FM is still a controversial topic.

Objectives:

The aim of this study was to analyse the data from a web-based registry of FM patients in order to detect a relationship between gender and disease severity.

Methods:

Adult patients with FM, diagnosed on the basis of the 2010/2011 American College of Rheumatology (ACR) diagnostic criteria (3), were recruited at 19 Italian rheumatology centres between November 2018 and April 2019. Those affected by other conditions that could interfere with the assessment of FM, e.g. psychiatric disorders, were excluded from the study. The severity of the disease was evaluated by validated FM-specific questionnaires: the revised Fibromyalgia Impact Questionnaire (FIQR) (4), the modified Fibromyalgia Assessment Status (ModFAS) questionnaire (5), and the Polysymptomatic Distress Scale (PDS) (6). The data obtained were collected in the Italian Fibromyalgia Registry, an online registry created with the support of the Italian Society of Rheumatology (SIR).

Results:

We analyse data from 2.381 patients affected by FM, 2.184 females (91.7%) and 197 males. No significant differences in mean age, disease duration, or BMI between the two genders were reported. The women expressed greater disease burden as indicated by higher scores for each completed test: higher mean ModFAS score (25.23 ± 8.83 Vs 23.37 ± 9.22; p = 0.005), mean FIQR score (58.62 ± 23.22 Vs 51.68 ± 23.06; p <0.001), and mean PDS score (18.77 ± 7.34 Vs 17.19 ± 7.25; p = 0.004). Figure 1 shows the mean scores of each item of the FIQR divided by gender. Women reported significantly higher values on all the items of FIQR except three (feeling overwhelmed, FIQR-11; depression, FIQR-16; and anxiety, FIQR-18). It is interesting to note that men self-reported higher levels of depression (FIQR-16).

Figure 1.

Mean scores for each FIQR item by gender.

Conclusion:

Our findings demonstrate that women with FM are globally more impaired than men (even if some psychological aspects of the disease are comparable), thus reinforcing the idea that gender plays a role in symptoms and functional impairments associated with the disease.

References:

[1]Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014;311:1547-55.

[2]Nascimento, et al. Gender role in pain perception and expression: an integrative review. BrJP. 2020; 3: 58-62

[3]Wolfe F, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: A modification of the ACR preliminary diagnostic criteria for fibromyalgia. J Rheumatol 2011;38:1113–22.

[4]Burckhardt CS, et al. The fibromyalgia impact questionnaire: development and validation. J Rheumatol 1991;18:728–33.

[5]Salaffi F, et al. Diagnosis of fibromyalgia: comparison of 2011/2016 ACR and AAPT criteria and validation of the modified Fibromyalgia Assessment Status. Rheumatol 2020; 0:1-8.

[6]Wolfe F, et al. Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population. Arthritis Care Res. 2013; 65:777–85

Disclosure of Interests:

None declared.

AB0057 IN VITRO EFFECT OF CTLA4-IGG ON M1-M2 SHIFT OF MACROPHAGES FROM RHEUMATOID ARTHRITIS PATIENTS

Background:

Among the cells involved in the inflammatory process of rheumatoid arthritis (RA) [1], macrophages play a key role through their capacity to polarize into “classically” or “alternatively” activated phenotypes (M1 or M2) and making macrophages important players for the inflammatory cascade or for the anti-inflammatory reaction, respectively [2]. CTLA4-Ig fusion protein (abatacept) has been shown to contribute to macrophage shift from M1 to M2 [3].

Objectives:

We aimed to investigate the effects of abatacept to induce the polarization from the pro-inflammatory M1 phenotype into the anti-inflammatory M2 phenotype in cultured human macrophages obtained from RA patients’ and healthy subjects’(HS) circulating monocytes.

Methods:

Cultured monocytes were isolated from peripheral blood mononuclear cells (PBMCs) of three early RA patients and ten HS, after signing informed consent and Ethics Committee approval. Cells were treated with phorbol myristate acetate (PMA) [5ng/ml] for 24 hours (hrs) to induce their differentiation into monocyte-derived macrophages (MDMs). Therefore, cultured HS MDMs were stimulated with lipopolysaccharides [LPS, 1mg/mL] for 4hrs [4] in order to induce their polarization into a pro-inflammatory M1 phenotype and then treated or not with abatacept at the concentrations of 100mg/mL and 500mg/mL for 3, 12, 24 and 48hrs. Cultured RA MDMs, were directly treated with abatacept as previous described. Cultured HS and RA MDMs without any pro-inflammatory stimuli and abatacept treatment were used as respective control.

The transition of MDMs from M1 to M2 phenotype was evaluated through gene expression and protein synthesis of M2 macrophage markers, namely scavenger receptors (CD163 and CD204), and mannose receptor-1 (CD206) by quantitative real-time polymerase chain reaction (PCR) and by Western blotting. The statistical analysis evaluation was carried out by GraphPad Prism 8 analysis software using the Wilcoxon non-parametric t-test. Any p-value lower than 0.05 was considered as statistically significant. Results were indicated as median±standard deviation (SD).

Results:

In cultured RA MDMs (three cases), abatacept upregulated the gene expression of all investigated M2 markers, specifically after 12hrs of treatment with the concentration of 100mg/mL. In these cells, abatacept upregulated only the CD204 protein synthesis with more evidence at 24hrs of treatment and with the 500mg/mL concentration. In cultured HS MDMs (ten cases), abatacept upregulated the gene expression of M2 markers, significantly for that of CD206 [at 3hrs with 100mg/mL concentration, p= 0.0312] and CD163 [at 12hrs with 500mg/mL concentration, p= 0.0312]. Moreover, in these cells, abatacept significantly upregulated the protein synthesis of CD206 [at 48hrs with 500mg/mL concentration, p= 0.0195] and CD204 [at 24hrs with 100mg/mL concentration, p= 0.0156; both at 24 and 48hrs with 500mg/mL concentration, p= 0.0234].

Conclusion:

Preliminary data seem to indicate that abatacept can promote the in vitro shift from the M1 into the M2 macrophage phenotype, by upregulating specific markers (CD163, CD204, CD206) in cultured M1-MDMs from RA patients and in M1 macrophages induced from HS.

References:

[1]McInnes IB, et al. N Engl J Med 2011;365:2205–19.

[2]Fujii M, et al. Biochem Biophys Res Commun. 2013;438(1):103-9.

[3]Cutolo M, et al. Arthritis Res Ther. 2009;11:R176.

[4]Pelegrin P., Surprenant, A. EMBO J. 2009 Jul 22; 28(14): 2114–2127.

Disclosure of Interests:

Samuele Tardito: None declared, Stefano Soldano: None declared, Emanuele Gotelli: None declared, Paola Montagna: None declared, Sabrina Paolino: None declared, Vanessa Smith: None declared, Maurizio Cutolo Grant/research support from: I received grant/research support from Bristol-Myers Squibb, Boehringer, Celgene.

AB0716 FIBROMYALGIA SYNDROME SEVERITY ACCORDING TO AGE CATEGORIES: RESULTS FROM A NATIONAL REGISTER

Background:

Fibromyalgia syndrome (FM) is characterised by a complex symptom spectrum, dominated by the presence of chronic widespread pain, fatigue and unrefreshing sleep. FM affects between 2 and 3% of the general population. It is a condition that mainly involves middle-aged women, although it is increasingly being diagnosed in younger people. The severity of symptoms can vary greatly between individual patients, and is influenced by many factors (e.g. sex, body mass index) [1]. To date, there is little information about changes in severity in accordance with patient age.

Objectives:

The aim of this study was to investigate variations in symptom severity in FM patients according to age categories.

Methods:

A cross-sectional study of adult FM patients diagnosed according to the American College of Rheumatology 2010/2011 criteria was performed. The case series was included from an Italian national registry [2]. Patients were grouped according to five age categories: 18-40 years, 41-50 years, 51-60 years, 61-70 years, over 71 years. Symptom severity was assessed through the revised Fibromyalgia Impact Questionnaire (FIQR) and domains, including FIQR physical function (items 1-9), FIQR health status (items 10-11), and FIQR symptoms (items 12-21). Between-group characteristics were analysed using one-way analysis of variance (ANOVA).

Results:

This study included a total of 2889 patients, 403 aged 18-40 years, 756 aged 40-50 years, 1035 aged 50-60 years, 528 aged 60-70 years, and 167 over 70 years, respectively. The mean (standard deviation [SD]) score of the total FIQR was 52.68 (11.82). Total FIQR and individual domains all showed a normal distribution. Analysing the data by age category, there were statistically significant differences between the categories for the total FIQR (p = 0.030). The age categories with the highest disease severity were those above 71 years (FIQR 62.14, SD 22.45), and between 51-60 years (FIQR 60.31, SD 22.89) (Table 1). Significant differences between age categories were also found for the domains physical function (p = 0.006) and health status (p = 0.012), but not for the domain symptoms (p = 0.164).

Table 1.

Mean values of FIQR total score and domains according to age categories.

FIQR and domains18-40 years41-50 years51-60 years61-70 years≥71 yearsp*FIQR total, mean (SD)57.90 (21.76)59.25 (23.30)60.31 (22.89)57.13 (23.59)62.14 (22.45)0.030FIQR physical function, mean (SD)15.51 (7.56)16.44 (7.77)16.77 (7.51)15.96 (7.82)17.68 (7.26)0.006FIQR health status, mean (SD)11.19 (5.85)11.24 (5.99)11.49 (5.93)10.57 (6.11)12.21 (5.97)0.012FIQR symptoms, mean (SD)31.32 (10.48)31.56 (11.32)32.10 (11.01)30.68 (11.47)32.24 (11.34)0.164

Abbreviations and legend. FIQR = revised Fibromyalgia Impact Questionnaire; SD = standard deviation; * = one-way analysis of variance (ANOVA).

Conclusion:

Distinguishing the disease severity in FM patients according to age categories, a bimodal distribution emerges, with the disease severity being greatest in patients over 71 years and in the 51-60 years decade. The main differences in severity, according to what can be detected through the FIQR, are attributable to the domains physical function and health status, which show higher scores in the two classes with higher severity.

References:

[1]Sarzi-Puttini P et al., Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nat Rev Rheumatol 2020; 16: 645–660.

[2]Salaffi F et al., The Italian Fibromyalgia Registry: a new way of using routine real-world data concerning patient-reported disease status in healthcare research and clinical practice. Clin Exp Rheumatol 2020; Suppl 123: 65-71.

Acknowledgements:

Società Italiana di Reumatologia (SIR) and Italian Ministry of Health

Disclosure of Interests:

None declared

POS0862 NAILFOLD CAPILLAROSCOPY IN UNDIFFERENTIATED AND MIXED CONNECTIVE TISSUE DISEASES

Background:

Microvascular damage is a frequent feature in connective tissue diseases (CTDs) and can be easily detected trough nailfold videocapillaroscopy (NVC) (1,2). Mixed and Undifferentiated connective tissue diseases (MCTD and UCTD) do not show a specific and unique NVC pattern (3). However, a variety of microvascular abnormalities can occur in these two CTDs, both non-specific or specific for the scleroderma like-pattern (3-5).

Objectives:

To retrospectively assess and compare nailfold microangiopathy observed by NVC in MCTD and stable UCTD versus primary Raynaud’s phenomenon (PRP) (6). In addition, the aim was to correlate NVC findings with serum levels of autoantibodies (Abs) against extractable nuclear antigen (ENA) detected in UCTD.

Methods:

Files of fourty-six MCTD patients (Kasukawa’s criteria) (mean age 42.8±16 SD years), fourty-seven UCTD patients (mean age 47.7±16.1 SD years), fifty-one PRP (mean age 45.9±17.3 SD years) were retrospectively evaluated in the study. Among UCTD and MCTD patients 95% of both showed Raynaud’s phenomenon. Main NVC parameters (i.e. dilated capillaries, giant capillaries, microhemorrhages, abnormal shapes and number of capillaries) and related semiquantitative scale (score 0–3 for every parameter), were analyzed and compared between the two distinct CTD groups and PRP. Furthermore, ENA Abs (in particular, Ro/SSA, La/SSB, Scl70 and Jo1) were evaluated. The CTD patients were receiving different immunosuppressive treatments. Statistical analysis was performed by non-parametric tests.

Results:

Among UCTD group, 36% of patients showed a normal NVC pattern, 53% had non-specific NVC abnormalities and 11% had a scleroderma like-pattern. The latter was significantly more frequent in MCTD than in UCTD (p<0.001), in fact 22 out of 46 (48%) MCTD patients presented a scleroderma-like pattern. On the other hand, normal pattern or non-specific NVC abnormalities were respectively found in 9% and 43% MCTD patients. Therefore, CTD patients showing giant capillaries, abnormal shapes (i.e. angiogenesis) and lower capillary density were significantly more affected by MCTD than UCTD (p<0.001). Finally, the absolute number of capillaries was found significantly lower in MCTD versus UCTD patients (mean 7±1.7 SD vs mean 9.2±1 SD, respectively, p<0.001). Not any statistical correlation was observed between NVC parameters and specific Abs ENA in UCTD. PRP showed a normal NVC pattern in 2% and non-specific capillary abnormalities in 98%, (including dilated capillaries and microhemorrhages).

Conclusion:

NVC features in UCTD patients seem very close to the pattern observed in PRP (mostly non-specific capillary abnormalities), conversely in MCTD the scleroderma-like pattern was found significantly prevalent together with a significant capillary number reduction. The transition from the scleroderma-like to the scleroderma pattern (mean systemic sclerosis) is matter of actual investigation.

References:

[1]Cutolo M. et al. Best Pract Res Clin Rheumatol 2008; 22:1093-108.

[2]Sulli A, Ann Rheum Dis. 2008;67:885-7.

[3]Smith V. et al. Autoimmunity Reviews 2020; 19:102458.

[4]De Holanda Mafaldo DA, et al. Lupus. 2007; 16:254–8.

[5]Smith V, et al. Ann Rheum Dis 2010; 69: 1092-96.

[6]Antunes M, et al. RMD Open. 2019, 26;4.

Disclosure of Interests:

None declared

AB0679 NAILFOLD VIDEOCAPILLAROSCOPY RESULTS IN COVID-19 PATIENTS RECOVERED FROM DIFFERENT DISEASE SEVERITY

Background:

COVID-19 is a multifaceted condition with a wide range of clinical manifestations, including microvascular/endothelial dysfunction, that starts in the early phase of the disease and may become dramatically harmful in the late stage, causing a massive pro-thrombotic state. Nailfold videocapillaroscopy (NVC) is the most used tool to identify microvascular status in a large spectrum of diseases [1]. Recently, non-specific NVC abnormalities have been described in a cohort of COVID-19 patients (no controls used) [2].

Objectives:

To assess microvascular damage in recovered COVID-19 patients (range of 40-270 days from recovery) by considering the previous severity of the disease, and, as mandatory, the comparison with matched individuals suffering from primary Raynaud’s phenomenon (PRP) and healthy volunteers (HV).

Methods:

NVC investigations were performed during standard clinical assessments in forty-four recovered COVID-19 patients (mean age 58±14 years, mean days from disease onset 129±54, mean days from disease recovery 106±52), twenty-two patients with PRP (mean age 60±15 years, mean years from disease onset 11±10) and twenty-two HV (mean age 60±14 years). COVID-19 patients were divided into two subgroups, according to the need of oxygen supplementation: twenty-two patients with severe lung involvement (need of Continuous Positive Airways Pressure and/or mechanical ventilation, mean age 57±12 years) vs twenty-two patients with mild-moderate lung involvement (need of Venturi mask or no need of oxygen supplementation, mean age 59±15 years). Clinical and demographic data of all the enrolled subjects were collected, during NVC examination. The following capillaroscopic parameters were evaluated: capillary number, dilated capillaries, giant capillaries, microhemorrhages, angiogenesis, disorganization of the microvascular array. A validated semiquantitative scoring (0-3) was adopted for NVC abnormalities [3-5]. Statistical analysis was carried out by non-parametric tests.

Results:

After COVID-19 recovery, no statistically significant difference was observed between COVID-19 patients and control groups of subjects concerning the score for the following NVC parameters: dilated capillaries, giant capillaries, disorganization of the microvascular array, angiogenesis. However, the capillary number per linear millimeter was significantly lower in COVID-19 patients (8.3±0.9) than in PRP (8.8±0.7, p=0.05) and HV (9.3±0.6, p<0.0001). Surprisingly, recovered COVID-19 patients showed significantly less microhemorrhages (score 0.4±0.3) than subjects of the other groups (PRP 0.6±0.5, p=0.01; HV 0.6±0.6, p=0.05). In particular, recovered patients who had more severe COVID-19 showed less microhemorrhages than patients with mild/moderate disease (score 0.18±0.4 vs 0.36±0.5), but this didn’t reach the statistical significance (p=0.18). On the other hand, patients recovered from severe SARS-CoV-2 infection also showed higher rate of angiogenesis (0.18±0.4) than patients with mild/moderate disease (no case, p=0.04).

Conclusion:

COVID-19 doesn’t seem to significantly induce, in short-term, specific alterations in peripheral microvascular array as evaluated by NVC, despite the severity of the disease, except for a significant reduction of the absolute number of nailfold capillaries. The topic needs longer time of evaluation and larger number of COVID-19 recovered cases to also assess the role of concomitant therapies.

References:

[1]Ingegnoli F et al. Curr Rheumatol Rev. 2018;14:5-11.

[2]Natalello G et al. Microvasc Res. 2021;133:104071.

[3]Smith V et al. Autoimmun Rev 2020;19:102458.

[4]Cutolo M et al. Clin Rheumatol. 2019;38:2293-2297.

[5]Sulli A et al. Ann Rheum Dis. 2008;67:885-7.

Disclosure of Interests:

None declared

AB0330 ANTIPHOSPHOLIPID ANTIBODIES AND ANTICOAGULANT TREATMENT: CAPILLAROSCOPIC FINDINGS

Background:

Antiphospholipid syndrome (APS) is an autoimmune condition characterized by arterial and/or venous thrombosis and/or obstetric morbidity, associated with the presence in the serum of antiphospholipid antibodies (aPL) [1]. Subjects with confirmed positivity of aPL in absence of thrombotic/obstetric manifestations are identified as aPL carriers [2] The microangiopathy detected by nailfold videocapillaroscopy (NVC) in APS and in aPL-carrier patients is poorly investigated, as well as the possible interference of anticoagulant drugs [3].

Objectives:

To compare microvascular damage in APS, aPL carriers and a group of patients (CTR) without aPL positivity and on regular warfarin therapy for cardiovascular indications

Methods:

NVC investigations were performed as part of standard procedures in APS patients (18, mean age 50.0±12.8 years), aPL carriers (24, mean age 46.4±16.4 years) and CTR without aPL (18, mean age 74±12.5 years) in therapy with oral anticoagulant (warfarin) for non-immunological vascular complications (atrial fibrillation, mechanical heart valve, deep venous thrombosis). Only patients affected by primary APS form were selected from data files (2006 Sapporo classification criteria). The following NVC parameters were availble: dilated capillaries, giant capillaries, microhemorrhages (with particular attention to linear and thin hemosiderin deposits, arranged perpendicularly and parallel to the nailfold bed, “comb-like”), abnormal shape (i.e. brunched “bushy” capillaries) and capillary number reduction. Those parameters were scored according to a semi-quantitative scale [4,5]. Statistical analysis was performed by non-parametric tests. Any p values equal or lower than 0.05 was considered statistically significant.

Results:

APS patients showed a higher score for dilated capillaries (p=0.001), more frequent microhemorrhages (p=0.03), in particular “comb-like” microhemorrhages (p=0.007) than simply aPL carriers. Of note, there wasn’t a statistically significant difference in the number of microhemorrhages between APS and CTR group (p=0.23), but again the number of “comb-like” hemorrhages, was almost absent in the CTR group (p=0.03). No significant correlation was found between the different aPL subtypes and the NVC parameters.

Conclusion:

APS patients showed significantly higher number of non-specific NVC abnormalities than aPL carriers. Anticoagulant treatment could represent a further risk factor for the appearance of microhemorrhages in all the patients, being the NVC “comb-like“ pattern mainly associated with the APS. Further investigations with larger cohorts of patients are needed for the definition of a possible APS specific NVC-pattern.

References:

[1]Ruiz-Irastorza G et al. Lancet. 2010;376(9751):1498-509. 2. Pengo V et al. Semin Thromb Hemost. 2012;38:322-7. 3. Sulli A et al. J Rheumatol. 2000;27:1574-6. 4. Smith V et al. 2020. Autoimmun Rev. 19:102458. 5. Sulli A et al. Ann Rheum Dis. 2008;67:885-7.

Disclosure of Interests:

None declared

AB0438 SERUM HOMOCYSTEINE AND BONE STATUS IN SYSTEMIC SCLEROSIS PATIENTS

Background:

Systemic sclerosis (SSc) is a complex autoimmune connective tissue disease characterized by self-amplifying microvascular damage sustained by autoimmune response and progressive skin and visceral fibrosis. Besides, SSc patients show higher incidence of bone micro/macroarchitectural damages and bone fractures. Emerging data demonstrate that high serum levels of homocysteine (Hcy) could modulate osteoclastogenesis and are recognized as risk factors for osteoporosis (2). Furthermore, serum levels of Hcy were found to be higher in SSc patients than in healthy controls (3).

Objectives:

to evaluate the bone status according to HCy serum levels in a cohort of SSc patients.

Methods:

20 female patients fulfilling ACR 2013 criteria for SSc underwent a dual-energy X-ray absorptiometry scan (DXA) (Lunar Prodigy) to evaluate bone status. We analysed bone quantity and quality respectively by bone mineral density (BMD) and trabecular bone score (TBS). According to the WHO criteria, osteoporosis was defined as a bone density of 2.5 standard deviations below that of a young adult (T-Score). Fasting blood samples were obtained from all patients in order to test serum Hcy level and bone turnover markers after obtaining the informed consent. All subjects underwent morphometric spine X-Ray to evaluate vertebral fractures. Statistical analysis was performed using non-parametric tests.

Results:

The mean age of patients was 64.15 ± 10.8 years with a mean disease duration of 9.1 ± 2.3 years. The mean modified Rodnan Skin Score (mRSS) was 10.7 ± 8.5. All patients showed a “scleroderma pattern” at nailfold Videocapillaroscopy (NVC): in particular, 7 patients showed the “Late” pattern, 9 patients the “Active” pattern and 4 patients the “Early” NVC pattern. Hyperomocisteinemia (HHcy) was found in 25% of patients. Interestingly, SSc patients with the “Late” NVC pattern showed a significantly higher serum level of Hcy compared to the “Early/Active” group (11.15 ± 4.4 vs 17.17 ± 6.4, p=0.03). No significant differences were observed in relation to the autoantibody profiles. Of note, 60% of patients with HHcy were found osteoporotic and 40% had bone fractures.

Considering the bone status, patients with Hcy showed a significantly lower TBS (p=0.03); the average values of BMD on the lumbar spine (p=0.79) and femoral neck (p=0.13) were found lower compared to, but without any statistical significance. Furthermore, no significant differences were observed in bone turnover markers according to Hcy levels.

Conclusion:

The study demonstrates a relationship between higher levels of Hcy and lower TBS values within SSc patients, particularly in those with most severe microvascular damage al NVC (“Late” SSc pattern). Therefore it is concluded that higher serum levels of Hcy associate to both bone microarchitectural and microvascular damage in SSc.

References:

[1]Cutolo M et al Expert Rev Clin Immunol 2019; 15: 753-64

[2]Behera J et al. J Cell Physiol 2017;232(10):2704-2709

[3]Yan-lie Zhang et al. Rheumatol 2018; 28(4):681-689

Disclosure of Interests:

None declared

Body composition and bone status in relation to microvascular damage in systemic sclerosis patients

AIM

To evaluate, in Systemic sclerosis (SSc) patients, the body composition and the bone status according to the peripheral microcirculatory condition, assessed and scored by nailfold videocapillaroscopy (NVC, "Early", "Active", "Late" patterns).

METHODS

Body composition and bone mineral density (BMD) were assessed by Dual X-ray absorptiometry and dedicated software (GE Lunar USA) in 37 female SSc patients classified according to the 2013 EULAR/ACR criteria and 40 sex-matched healthy subjects. Clinical, laboratory, body composition and bone parameters were analyzed according to the different NVC patterns. Means were compared by the Student's t test or one-way analysis of variance; medians were compared by the Kruskal-Wallis test; and frequencies by the chi-square test.

RESULTS

Higher prevalence of vertebral (21% vs 7%) and femoral (35% vs 7%) osteoporosis (OP) was found in SSc. Particularly SSc patients with "Late" NVC pattern showed a significantly higher prevalence of vertebral (p = 0.018) and femoral OP (p = 0.016). Regional assessment of bone mass (BM) in seven different body areas showed a significantly lower BMD only at the total spine (p = 0.008) and femoral neck (p = 0.027) in advanced microvascular damage. Patients with "Late" NVC pattern showed a lower whole-body lean mass (LM) compared to "Early" and "Active" NVC patterns, particularly at upper limbs. To note, in all body sites, BMD correlates with LM and BMC according to NVC pattern severity.

CONCLUSIONS

SSc patients with most severe microvascular damage show a significantly altered body composition and bone status suggesting a strong link between microvascular failure and associated muscle/bone sufferance.

Management of giant cell arteritis among general practitioners from Genoa, Italy: a web-based survey

Giant cell arteritis (GCA) is the most common form of vasculitis of the adult. General practitioners (GPs) are usually the first physicians who take care of GCA patients. In this study, the awareness of GPs from Genoa, Italy, regarding GCA was investigated by a web-based survey. A web-based questionnaire was sent by mail to 775 Italian GPs. It included 12 multiple choice questions regarding practice seniority, practice population size, number of GCA patients followed, and GPs' diagnostic and therapeutic approach. Of the 775 GPs involved, 76 (9.8%) answered. Thirty-three/75 (44%) declared that they did not see patients with GCA and the remaining 42 (56%) that they diagnose between one and two patients per year. New headache onset was the presenting feature of GCA for the majority of GPs (78.3%). GCA was diagnosed on the basis of clinical presentation alone by 35.2% of them, of temporal artery biopsy by 49.3%, and by imaging, including ultrasound and magnetic resonance imaging, by 15.5%. The referral pattern was mainly toward rheumatologists (68.5%). Only 27.8% GPs declared they start treatment at the first clinical suspicion, with the others waiting for laboratory and imaging examinations or specialist consultation. The doses of glucocorticoids used were in keeping with current guidelines. The management of GCA by GPs from Genoa is in general correct, with the exceptions of excessive confidence in headaches for diagnosis and of the timing of GC initiation. These points suggest that a program of information and education for GPs is warranted.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Progression of nailfold capillaroscopic patterns and correlation with organ involvement in systemic sclerosis: a 12 year study

OBJECTIVE

The aim of this observational study was to investigate the evolution of scleroderma microangiopathy throughout different nailfold videocapillaroscopy (NVC) patterns ('early', 'active', 'late') as well as the prevalence of organ involvement in SSc patients during a 12-year follow-up.

METHODS

Thirty-four SSc patients showing at baseline (first capillaroscopic analysis) the 'early' NVC pattern of microangiopathy were enrolled and followed for 12 years (s.d. 2). Complete NVC analysis and clinical and serological findings were collected. Patients were in a standard therapeutic care setting. Statistical analysis was carried out by non-parametric tests.

RESULTS

After a 12-year follow-up, the 'early' NVC pattern changed from baseline in 76% of the patients. The NVC pattern was found to be 'active' in 9 patients (26%), 'late' in 13 (38%) and characterized by non-specific capillary abnormalities in 4 (12%). In the subgroup whose microangiopathy progressed from the 'early' to the 'late' NVC pattern, the median time of progression from the 'early' to the 'active' pattern was significantly shorter (11 months) when compared with patients who progressed from the 'early' to the 'active' NVC pattern (55 months) (P = 0.002). The median time of progression between NVC patterns was significantly shorter in SSc patients showing either a nucleolar ANA pattern or Scl70 autoantibodies (P = 0.048). Organ involvement was progressively greater in SSc patients with 'early', 'active' and 'late' NVC patterns, respectively.

CONCLUSIONS

This longitudinal study confirms over a 12-year follow-up the evolution of specific NVC patterns associated with the progressive severity of organ involvement in SSc patients in a standard clinical care setting.

A seasonal pattern in the onset of polymyalgia rheumatica and giant cell arteritis? A systematic review and meta-analysis

OBJECTIVES

Studies on the seasonality of onset of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) have shown conflicting results. The aim of this systematic literature review and meta-analysis is to determine from aggregated data whether there is a seasonal distribution for these diseases.

METHODS

A literature search was performed using Pubmed Central and Embase scientific databases. The incidences per 6-month periods, season or month of onset, that were reported in the studies were summarised in tables considering the two diseases as separate conditions or together. The Incidence Rate Ratio (IRR) for the cold period versus the warm period was pooled across studies by random effects meta-analysis weighed by inverse variance. Funnel plots and Egger test were used to explore possible publication biases. A sensitivity analysis was performed to weigh articles with a disproportionate number of patients compared to the rest.

RESULTS

In the scientific literature 22 suitable papers were found: 6 on PMR with 803 patients, 11 on GCA with 2,807 patients, and 5 studies considering both diseases with 19,613 patients. There was considerable heterogeneity amongst studies regarding their quality, the classification criteria used, and the definition of onset of symptoms. No seasonal aggregation was found for GCA and PMR. The pooled IRR estimate of the meta-analysis (1.13[0.89,1.36]) showed a non-significant, higher frequency of diseases onset in the warm season.

CONCLUSIONS

Our meta-analysis did not confirm a seasonal onset for PMR and GCA.

SAT0293 EXOSOMES DERIVED FROM PLASMA OF SYSTEMIC SCLEROSIS (SSC) PATIENTS AND FROM SSC CULTURED FIBROBLASTS CONTAIN PRO-FIBROTIC MIRNA SIGNATURES AND COULD INDUCE MYOFIBROBLAST DIFFERENTIATION IN VITRO

Background:

Exosomes generated great resonance in the last few years due to their important roles in different biological pathways and diseases, including systemic sclerosis (SSc) (1). They are lipid-like nanovesicles containing biomarkers, such as proteins, lipids, macromolecules and nucleic acids, including microRNA (miRNA) (2). Exosomes are implicated in intercellular communication by fusing and releasing their cargo into the target cells (3).

Objectives:

In the present study, we evaluated the potential of exosomes deriving from plasma of SSc patients or generating from cultured SSc fibroblasts to drive the fibrotic signaling in the disease.

Methods:

Exosomes were isolated from plasma of n=10 SSc patients and from n=10 control subjects. Exosomes were also purified from cell culture supernatants of SSc fibroblasts and of control fibroblasts. Exosome size and concentration were assessed by Nanosight Particle Tracking Analysis (NTA) and by transmission electron microscopy (TEM). The content of anti-fibrotic (let-7a, 146a, 200a, 223a) and pro-fibrotic (150, 155) miRNAs was assessed in all the plasma-derived and cell culture-derived exosome populations by semiquantitative real time PCR. Finally, isolated exosomes were used to stimulate control dermal fibroblasts in culture. Gene expressions (COL1A1, ACTA2 and TAGLN) were assessed by quantitative real time PCR (qRT-PCR) and protein levels (type-I-collagen, α-SMA and SM22) by immunofluorescence (IF).

Results:

Exosomes isolated from SSc plasma samples showed higher concentration (3.3x1010±1.1x1010particles/mL) compared to those isolated from control plasma ones (1.5x1010±0.4x1010particles/mL) (p<0.01). The exosome size did not differ between SSc and control plasma samples and ranged from 50nm to 150nm. Similar results were obtained with exosomes generated from fibroblast cultures: the concentration was higher in SSc fibroblasts (1.1x1010±0.2x1010particles/mL) than in control ones (0.4x1010±0.1x1010particles/mL) (p<0.05) with no significant differences in size distribution. The content of all anti-fibrotic (let-7a, 146a, 200a, 223a) miRNAs was decreased in exosomes coming from both SSc plasma samples and from SSc fibroblasts with respect to control plasma samples (p<0.05) and to control fibroblasts (p<0.05). On the contrary, the pro-fibrotic (150, 155) miRNAs were significantly upregulated in exosomes deriving from SSc plasma samples and from SSc fibroblasts, with respect to control plasma samples (p<0.05) and to control fibroblasts (p<0.05). Finally, only exosomes coming from SSc plasma samples or SSc fibroblast cultures were able to induce pro-fibrotic gene (COL1A1, ACTA2 and TAGLN) and protein (type-I-collagen, α-SMA and SM22) expression in control fibroblasts. No pro-fibrotic induction was seen in presence of exosomes isolated from control plasma samples or control fibroblast cultures.

Conclusion:

This study demonstrates that plasma from SSc patients contains higher concentration of exosomes compared to plasma from control subjects and SSc-derived exosomes contain specific pro-fibrotic miRNA signatures that can induce myofibroblast differentiationin vitro. These results suggest that exosomes could be fibrotic drivers towards non-affected areasin vivo, and they might represent novel targets for precision medicine treatments in SSc.

References:

[1]Zhu T, Wang Y, Jin H, Li L. The role of exosome in autoimmune connective tissue disease. Ann Med. 2019 Mar;51(2):101-108.

[2]Wermuth PJ, Piera-Velazquez S, Rosenbloom J, et al. Existing and novel biomarkers for precision medicine in systemic sclerosis. Nat Rev Rheumatol. 2018 Jul;14(7):421-432.

[3]Colletti M, Galardi A, De Santis M, et al. Exosomes in Systemic Sclerosis: Messengers Between Immune, Vascular and Fibrotic Components? Int J Mol Sci. 2019 Sep 4;20(18). pii: E4337.

Disclosure of Interests:

Claudio Corallo: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Stefano Soldano: None declared, Enrico Selvi: None declared, Francesca Bellisai: None declared, Nicola Giordano: None declared

FRI0257 CAPILLAROSCOPIC VERY EARLY MORPHOLOGICAL AND QUANTITATIVE SPECIFIC ABNORMALITIES ANTICIPATE THE DEVELOPMENT OF THE “SCLERODERMA PATTERN” IN PATIENTS WITH RAYNAUD’S PHENOMENON

Background:

Nailfold videocapillaroscopy (NVC) abnormalities in subjects with isolated Raynaud’s phenomenon (RP) may be present before transition to secondary RP(SRP) and development of a NVC “scleroderma pattern” and are known to predict for evolution to a connective tissue disease (CTD) within few years [1]. In a previous study, we have demonstrated that the very early increase of capillary diameter over 30 μm is an independent predictor for development of Systemic Sclerosis (SSc) associated SRP [2].

Objectives:

Present pilot retrospective study aimed to investigate in a cohort of patients affected by CTD–related RP the presence of very early capillaroscopic morphological and quantitative abnormalities in the acquired pictures of NVC performed before the development of the NVC scleroderma-pattern. In particular, the study was addressed to identify a “very early”scleroderma pattern, in order to intercept patients with RP at high risk of evolution in a CTD, specifically SSc.

Methods:

We selected the NVCs of 273 SSc patients presenting one of the validated NVC “scleroderma patterns”. We enrolled 26 SSc patients having a NVC analysis performed before the development ofthe “very early”NVC pattern. As controls, we evaluated 26 patients affected by other CTDs with stable non-scleroderma pattern over time. The 16 images per patient obtained by NVC examination were analyzed for total number of capillaries, number and the limbs diameters of capillaries with a diameter >30 μm, and microhemorrhages. Statistical analysis was performed using non-parametric tests.

Results:

All 26 SSc patients showed dilated capillaries with a diameter >30 μm in their previous NVC. Patients later developing scleroderma pattern had statically higher number and percentage of capillaries with a diameter >30 μm (p=0.0004 and p=0.0005), as well as a larger apical dilatation >40 μm (p=0.002). A progressive and significant increase in all capillary diameters were only detected in patients later diagnosed for SSc (apical p=0.006, venous p=0.02, arterial p=0.03). A significant homogeneous and progressive dilation was observed from the apical region and then involving both venous and arterial branches, only in SSc patients (p=0.002).

Conclusion:

Present pilot study demonstrates, for the first time that, before to develop a validated NVC scleroderma-pattern, all potential SSc patients present significant very early morphological and quantitative NVC changes. In particular, the progressive and homogeneous capillary loop dilation over 40 μm in over 40% of total number capillaries significantly could contribute to identify RP patients who will develop a SSc pattern after 4-5 years.

References:

[1]Cutolo M, Sulli A, Pizzorni C, Accardo S. Nailfold videocapillaroscopy assessment of microvascular damage in systemic sclerosis. J Rheumatol. 2000;27:155-60.

[2]Trombetta AC, et al. J Rheumatol 2016;43:599-606.

Disclosure of Interests:

Monica Pendolino: None declared, Carmen Pizzorni: None declared, Sabrina Paolino: None declared, Federica Goegan: None declared, Emanuele Gotelli: None declared, Carlotta Schenone: None declared, Francesco Cattelan: None declared, Massimo Patanè: None declared, Elisa Alessandri: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha

AB0578 LONG-TERM TOLERABILITY OF AMINAPHTONE IN A COHORT OF SYSTEMIC SCLEROSIS PATIENTS IN CONCOMITANT STANDARD THERAPY

Background:

Aminaphtone (AMI) is a bioflavonoid compound, classically used for “capillary disorders”.In vitroAMI interferes with adhesion molecules (sELAM-1 and sVCAM-1) and with vascular endothelial cadherin degradation thus defending vessels permeability. Moreover, it counteracts vasoconstriction, downregulating endothelin-1 production at a gene level (1-3).In vivoAMI ameliorates clinical symptoms of several clinical conditions, above all Raynaud’s phenomenon (RP), either primary or secondary to systemic sclerosis (SSc), as demonstrated by a recent six-month study (4).

Objectives:

To evaluate long-term tolerability of standard dosage of AMI in a real-life cohort of SSc patients with secondary RP.

Methods:

Seventy-eight SSc patients (mean age 65±13 years; mean disease duration 9±7 years) treated with AMI due to active RP were enrolled (ACR/EULAR 2013 criteria). They were taking various concomitant treatments, including aspirin, calcium-channel blockers, cyclic intravenous iloprost, immunomodulators, endothelin receptor antagonists. SSc patients performed periodic clinical assessments and blood tests on average every four months per clinical practice. Duration of AMI administration, side effects, and self-assessment of Raynaud Condition Score (RCS) in a scale from 0 (absence of pain) to 10 (intolerable pain) were retrospectively taken into account.

Results:

Duration of AMI administration was between six and sixty-seven months (mean 31±20 months). AMI was administered at 75 mgbis in diedosage, as standard initial posology. At baseline, mean RCS was 7.3±0.8. After 3 months of treatment sixty-four patients (82%) yet referred a subjective improvement of RCS (3.5±0.8, p=0.03), whereas 14 patients (18%) were clinically unsatisfied (RCS 6.1±0.4, p=1.12). In this last group, posology was increased to 75 mgtris in die, with a satisfactory amelioration in further nine patients (93,6%) (RCS 4.0±0.6 p=0.04), while five patients (6,4%) definitively discontinued therapy for subjective ineffectiveness within six months. Patients referred a sustained improvement of RCS along the observational period (31±20 months) (last RCS 3.7±0.7, p=0.03 vs baseline). During the follow-up, five patients (6,4%) referred headache as side effect: three of them had to reduce AMI posology to 75 mg per day, while maintaining clinical benefits. Periodic blood tests did not reveal any significant alteration attributable to AMI. No other side effects related to the drug appeared during the treatment period.

Conclusion:

AMI shows an acceptable medium-long-term tolerability along with sustained efficacy in the management of SSc-related RP, without disabling side effects. However, the retrospective design, the absence of a placebo-control group and the concomitant standard therapy limit the results, and a randomized controlled trial for AMI use in the management of SSc-related RP is desirable.

References:

[1]Scorza R et al. 2008.Clin Ther30(5):924-9.

[2]Felice F et al. 2018.Phlebology33(9):592-599.

[3]Scorza R et al. 2008.Drugs R D9(4):251-7.

[4]Ruaro B et al. 2019.Front Pharmacol10:293.

Disclosure of Interests:

Emanuele Gotelli: None declared, Sabrina Paolino: None declared, Federica Goegan: None declared, Francesco Cattelan: None declared, Massimo Patanè: None declared, Carmen Pizzorni: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Alberto Sulli Grant/research support from: Laboratori Baldacci

AB0374 LUPUS LOW DISEASE ACTIVITY STATE AND MAINTAINING DRUG THERAPY: A RETROSPECTIVE INVESTIGATION

Background:

Systemic lupus erythematosus (SLE) is a chronic autoimmune multisystemic disease, that can begin with a wide range of clinical manifestations, and requires immunosuppressive therapies (1). A treat-to-target strategy leads to a high rate of clinical remission among patients (2). Several “remission” definitions have been provided in the last years and Lupus Low Disease Activity State (LLDAS) seems one of the best tools to evaluate it in clinical practice (3).

Objectives:

To evaluate the prevalence of SLE signs and symptoms at onset and the drugs used to induce and maintain the clinical remission, evaluated by LLDAS, in a real-life cohort of SLE patients.

Methods:

Thirty female SLE patients (mean age 52±15 years; mean age at disease onset 34±16 years, mean disease duration 18±13 years) in clinical remission have been enrolled (EULAR/ACR 2019 criteria) (4). Remission was defined by LLDAS (SLEDAI-2K < 4 and no activity in major organ systems, no hemolytic anemia; no new features of activity compared with previous assessment, physician global assessment (PGA) ≤ 1, prednisone dose ≤7.5 mg/day, well tolerated and stable therapy with maintenance doses of immunosuppressive drugs). Clinical and serological manifestations, SLEDAI-2K and pharmacological treatments were recorded at baseline and during follow-up.

Results:

Mucocutaneous involvement (57%), arthritis (30%), serositis (30%), nephritis (27%), leukopenia (23%), thrombocytopenia (20%), hemolytic anemia (13%), antiphospholipid syndrome manifestations (16%), neuro-psychiatric lupus symptoms (6%) were present in various combinations at disease onset. Baseline mean SLEDAI-2K was 10.5±2.5. Patients were treated with different dosages of glucocorticoids (100%), hydroxychloroquine (HCQ, 73%), cyclofosfamide (20%), mycophenolate mofetile (MMF, 13%), azathioprine (AZA, 13%), methotrexate (MTX, 13%), cyclosporine A (CSA, 6%), rituximab (3%), abatacept (ABA, 3%). Glucocorticoids were prescribed together with a single DMARD in 50% of cases and with two DMARDs in the remaining 50% of patients. Patients reached LLDAS remission after a mean time of 14±12 years, with a mean remission duration of 4.2±3.2 years (mean SLEDAI-2K at last visit 1±1; Mean PGA 0.4±0.1). Maintenance therapies during remission were prednisone ≤ 5 mg/day and/or HCQ ≤ 400 mg/day and/or CSA ≤ 200 mg/day and/or MTX ≤ 10 mg/weekly and/or MMF ≤ 2 g/day and/or AZA ≤ 100 mg/day. In particular, only prednisone 7%, only HCQ 3%, prednisone + HCQ 53%, prednisone + single DMARD (different from HCQ) 7%, prednisone + HCQ + DMARDs 30%.

Conclusion:

After reaching the clinical remission by a treat to target strategy, the administration of low dose of prednisone and HCQ in the majority of SLE patients (63%) seems useful to prevent new SLE flares. The retrospective design and the absence of a control group of patients with active disease limit this study.

References:

[1]Lisnevskaia L et al. 2014.Lancet384(9957):1878-1888.

[2]Van Vollenhoven RF et al. 2014.Ann Rheum Dis73(6): 958-967.

[3]Franklyn K et al. 2016.Ann Rheum Dis. 75(9): 1615-21.

[4]Aringer M et al. 2019.Arthritis Rheumatol.71(9): 1400-1412.

Disclosure of Interests:

Emanuele Gotelli: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci, Giorgia Ferrari: None declared, Greta Pacini: None declared, Carlotta Schenone: None declared, Massimo Patanè: None declared, Pietro Francesco Bica: None declared, Carmen Pizzorni: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Sabrina Paolino: None declared

THU0334 LASER SPECKLE CONTRAST ANALYSIS FOR MEASUREMENT OF PERIPHERAL BLOOD PERFUSION IN SYSTEMIC SCLEROSIS PATIENTS: CAN IT PREDICT FUTURE ISCHEMIC DIGITAL TROPHIC LESIONS?

Background:

Vasculopathy is a hallmark of systemic sclerosis (SSc). Laser speckle contrast analysis (LASCA) is a research tool to assess peripheral blood perfusion (PBP) (1). At this moment, its reliability has been attested in SSc patients, but its predictive value for future ischemic digital trophic lesions (DTL) is unknown (1).

Objectives:

To investigate in an unselected, prospective SSc cohort if baseline LASCA PBP measurements can discriminate between patients who will develop ischemic DTL (iDTL) and those who will not.

Methods:

Patients (fulfilling 2013 ACR/EULAR criteria and/or 2001 LeRoy and Medsger criteria) were recruited during the period of December 2017 to September 2018. LASCA was performed at baseline, in standardized conditions (1). Regions of interest (ROIs) (diameter 1 cm) were outlined at the 2nd-5thfingertip both volar and dorsal. The ‘average PBP’ of these ROIs was calculated (expressed in arbitrary perfusion units [PU]). A monthly telephone survey was conducted for 1 year to investigate DTL occurrence. DTL were considered ‘ischemic’ if not related to calcinosis. Logistic regression and ROC analysis were used to assess if average PBP is predictive of future iDTL.

Results:

Of the 106 patients with complete follow-up (92 women [86,8%]; 18 limited SSc [17,0%], 82 limited cutaneous SSc [77,4%], 6 diffuse cutaneous SSc [5,7%]), 29 patients (27,4%) had a DTL history. Forty-nine patients (46,2%) were on vasodilator therapy. Only 7 patients developed at least 1 iDTL during follow-up (6,6%) (Figure 1a). Performing univariate logistic regression (ULR), average PBP was not predictive for future iDTL (Table 1). Of note, analyzing only the patients not taking vasodilators, average PBP in the ‘iDTL group’ (n = 3) was median 46,8 PU (min. 45,6 - max. 68,8) vs. median 141,4 PU (min. 24,4 - max. 269,5) in the ‘no iDTL group’ (n = 54) (Figure 1b). In this subgroup, all 3 patients who developed iDTL (100%) had an average PBP ≤ 70 PU whereas only 9 of the 54 patients without iDTL development (16,7%) had such PBP values.

Table 1.

Results of ULR

Summary statisticsULRVariableiDTL cases(n = 7)Non-iDTL cases(n = 99)ParameterOR(95% CI)pROC AUC(95% CI)Average PBP (PU) mean (+/- SD)123,0 (74,6)142,9 (61,9)Average PBP (linear)0,995(0,982-1,007)0,4180,597(0,352-0,843)

Conclusion:

In this pilot study with an unselected day-to-day SSc population, where patients were allowed to continue vasodilators, there was an unexpected low iDTL incidence, undermining the power of our study. Even though, the observations in the subgroup of patients not taking vasodilators deserve future investigation to assess whether low PBP values, as measured by LASCA, are associated with a higher iDTL incidence.

References:

[1]Cutolo M, Vanhaecke A, et al. Autoimmun Rev. 2018;17(8):775-80.

Figure 1.

Distribution of ‘average PBP’ as measured by LASCA for ‘no iDTL group’ and ‘iDTL group’

Disclosure of Interests:

Claire Debusschere: None declared, Amber Vanhaecke: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Ellen Deschepper: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl

SAT0345 IS THERE A DIFFERENCE BETWEEN THE SEXES IN THE RATE OF PROGRESSION OF SYSTEMIC SCLEROSIS-ASSOCIATED ILD (SSC-ILD)? DATA FROM THE SENSCIS TRIAL

Background:

Previous studies suggested that male sex may be associated with a greater rate of decline in FVC in patients with SSc-ILD. In the SENSCIS trial, nintedanib reduced the rate of FVC decline over 52 weeks vs placebo.

Objectives:

Analyse the rate of decline in FVC and the efficacy and safety of nintedanib in the SENSCIS trial in subgroups by sex.

Methods:

Patients with SSc-ILD with first non-Raynaud symptom <7 years before screening and ≥10% fibrosis of the lungs on HRCT were randomised to nintedanib or placebo. We analysed the rate of decline in FVC (mL/year) and adverse events over 52 weeks in male and female patients.

Results:

Of 576 patients, 433 (75.2%) were female. Compared with males, the female subgroup included a smaller proportion of White patients (64.7% vs 74.8%), a smaller proportion on mycophenolate at baseline (46.9% vs 53.1%), a greater proportion of ATA positive patients (63.3% vs 53.1%), and had a lower mean weight at baseline (66.6 vs 79.1 kg). FVC % predicted (72.8% vs 71.7%) and mRSS (11.2 vs 10.8) were similar in females and males. The adjusted annual rate of decline in FVC in the placebo group was numerically greater in male than female patients (-126.8 [SE 29.0] vs -82.0 [16.2] mL/year). The estimated effect of nintedanib vs placebo on reducing the rate of decline in FVC was numerically more pronounced in males than females (difference: 58.6 [95% CI -18.0, 135.1] vs 34.6 [-9.3, 78.4] mL/year), but the interaction p-value did not indicate heterogeneity in the treatment effect between subgroups (p=0.59). Among nintedanib-treated patients, diarrhoea was reported in similar proportions of females and males (74.7% vs 79.1%); nausea, vomiting and liver test abnormalities were reported in greater proportions of females vs males (35.3% vs 19.4%, 28.1% vs 13.4%, and 15.4% vs 9.0%), while serious adverse events were more frequent in males (32.8% vs 21.3%). In the nintedanib and placebo groups, respectively, adverse events leading to treatment discontinuation were reported in 16.7% and 8.5% of females and 13.4% and 9.2% of males.

Conclusion:

In the SENSCIS trial in patients with SSc-ILD, the annual rate of decline in FVC in the placebo group was numerically greater in male than female patients. The rate of FVC decline was lower with nintedanib than placebo both in males and females. The safety profile of nintedanib was similar between males and females.

Disclosure of Interests:

Elizabeth Volkmann Grant/research support from: Forbius, Corbus Pharmaceuticals, Consultant of: Boehringer Ingelheim, Forbius, Speakers bureau: Boehringer Ingelheim, Serena Vettori Consultant of: Boehringer Ingelheim, John Varga Grant/research support from: John Varga is awaiting grants from Boehringer Ingelheim and has received grants from Bristol-Myers Squibb, Pfizer, Takeda, and TeneoBio, Consultant of: John Varga has acted as a consultant for Boehringer Ingelheim, Bristol-Myers Squibb, Emerald Health, and TeneoBio, Ariane Herrick: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Ana Cordeiro Consultant of: Ana Cordeiro has acted as a consultant for Roche, Speakers bureau: Ana Cordeiro has received speaker fees from Boehringer Ingelheim, Lilly, and Vitoria, Valderilio F Azevedo Grant/research support from: Abbvie, Janssen, Bristol-Myers Squibb, Boehringer-Ingelheim, Lilly and Novartis, Consultant of: Lilly, Novartis, Janssen, Boehringer-Ingelheim, Amgen, Pfizer and Abbvie, Speakers bureau: Sandoz, Celltrion, Lilly, Novartis, Janssen, Boehringer-Ingelheim, Amgen, Pfizer and Abbvie, Sindhu Johnson Grant/research support from: Boehringer Ingelheim, Corbus Pharmaceuticals, GlaxoSmithKline, Roche, Merck, Bayer, Consultant of: Boehringer Ingelheim, Ikaria, Christian Stock Employee of: Employee of Boehringer Ingelheim, Martina Gahlemann Employee of: Employee of Boehringer Ingelheim, Lizette Moros Employee of: Lizette Moros is an employee of Boehringer Ingelheim, Margarida Alves Employee of: Employee of Boehringer Ingelheim, Maureen Mayes Grant/research support from: Maureen Mayes has received grants from Boehringer Ingelheim, Corbus, CSL Behring, Eicos, and Galapagos, Consultant of: Maureen Mayes has acted as a consultant for Boehringer Ingelheim, Eicos, and Galapagos. She was a member of the SENSCIS trial Steering Committee (Boehringer Ingelheim)

THU0528 NAILFOLD VIDEOCAPILLAROSCOPY REPORTING IN CLINICAL RESEARCH: INTERNATIONAL DELPHI BASED CONSENSUS

Background:

Nailfold capillaroscopy (NVC), a non-invasive technique to assess microcirculation, is increasingly being incorporated into rheumatology routine clinical practice. Currently, the degree of description of NVC methods varies amongst research studies, making interpretation and comparison between studies challenging. In this field, an unmet need is the standardization of items to be reported in research studies using NVC.

Objectives:

To perform a Delphi consensus on minimum reporting standards in methodology for clinical research, based on the items derived from a systematic review focused on this topic.

Methods:

The systematic review of the literature on NVC methodology relating to rheumatic diseases was performed according to PRISMA guidelines (PROSPERO CRD42018104660) to July 22nd2018 using MEDLINE, Embase, Scopus. Then, a three-step web-based Delphi consensus was performed in between members of the EULAR study group on microcirculation in rheumatic diseases and the Scleroderma Clinical Trials Consortium. Participants were asked to rate each item from 1 (not appropriate) to 9 (completely appropriate).

Results:

In total, 3491 references were retrieved in the initial search strategy, 2862 were excluded as duplicates or after title/abstract screening. 632 articles were retrieved for full paper review of which 319 fulfilled the inclusion criteria. Regarding patient preparation before the exam, data were scarce: 38% reported acclimatization, 5% to avoid caffeine and smoking, 3% to wash hands and 2% to avoid manicure. Concerning the device description: 90% reported type of instrument, 77% brand/model, 72% magnification, 46% oil use, 40% room temperature and 35% software for image analysis. As regards to examination details: 76% which fingers examined, 75% number of fingers examined, 15% operator experience, 13% reason for finger exclusion, 9% number of images, 8% quality check of the images and 3% time spent for the exam. Then, a three-round Delphi consensus on the selected items was completed by 80 participants internationally, from 31 countries located in Australia, Asia, Europe, North and South America. Some items reached the agreement at the second round (85 participants), and other items were suggested as important to consider in a future research agenda (e.g. temperature for acclimatization, the impact of smoking, allergies at the application of the oil to the nailbed, significance of pericapillary edema, methods of reporting hemorrhages, ramified and giant capillaries). The final agreement results are reported below:

Conclusion:

On the basis of the available literature the description of NVC methods was highly heterogeneous and individual published studies differed markedly. These practical suggestions developed using a Delphi process among international participants provide a guidance to improve and to standardize the NVC methodology in future clinical research studies.

Disclosure of Interests:

Francesca Ingegnoli: None declared, Tommaso Schioppo: None declared, Ariane Herrick: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci, Francesca Bartoli: None declared, Nicola Ughi: None declared, John Pauling: None declared, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl

SAT0300 SERUM FROM “EARLY” SYSTEMIC SCLEROSIS PATIENTS ALREADY INDUCES THE ALTERNATIVELY ACTIVATED MACROPHAGE PHENOTYPE (M2) IN CULTURED HUMAN MONOCYTES

Background:

Alternatively activated (M2) macrophages seem to play a role in the fibrotic process of systemic sclerosis (SSc) as potential inducers of tissue fibrosis through their secretion of specific cytokines and chemokines, such as interleukin-10 (IL-10), macrophage derived chemokine (CCL-22) and pro-fibrotic metalloproteases (i.e. MMP9) (1-3).

Objectives:

To investigate the presence of circulating cells belonging to the monocyte lineage showing an M2 phenotype in SSc patients (pts) and possible correlation with the clinical parameters of the disease. Moreover, to investigate if the treatment of cultured monocytes isolated from healthy subjects with serum derived from early SSc pts may induce theirin vitropolarization into M2 macrophages.

Methods:

Fifty female SSc pts (mean age 64±13 yrs), fulfilling the EULAR/ACR criteria, and 27 gender-matched healthy subjects (HSs, mean age 57±7 yrs) were considered at the Rheumatology Division of Genoa University after written informed consent. Nailfold videocapillaroscopy (NVC), serum SSc-related antibodies and skin involvement were investigated. Circulating cells belonging to the monocyte populations (CD45+and CD14+cells) were characterised by flow cytometry using specific surface markers of M2 phenotypes (CD204, CD206, CD163). Each SSc pt had been under stable treatment regimen for at least six months. Cultured monocytes, isolated by negative selection from peripheral blood mononuclear cells (PBMCs) of 8 HSs, stimulated for 48 hrs with 10% of serum of lcSSc pts with “Early” NVC pattern, as well as serum of dcSSc pts with “Active” and “Late” NVC patterns. Cultured monocyte human cell line (THP1) was differentiated into macrophages (5ng/ml of phorbol myristate acetate) and then stimulated with SSc sera. The expression of CD204, CD206 (M2 markers) and CD68 was investigated by immunocytochemistry, whereas MMP9 secretion was investigated by zymography. Statistical analysis was performed using Mann-Whitney and Kruskal-Wallis tests, and correlations were explored by bivariate Pearson’s analysis.

Results:

In SSc pts the percentage of circulating M2 cells (CD14+CD204+CD163+CD206+cells) was significantly increased compared to both HSs and SSc pts not under immunosuppressive treatment (p<0.05) However, no correlation with skin involvement and SSc-related antibodies was observed. Cultured macrophages stimulated with SSc serum expressed CD204 and CD206 markers compared to the macrophages stimulated with HS serum (CD204 and CD206 double negative cells). Of note, the ability to express M2 markers was already evident in cultured macrophages stimulated with “Early” NVC SSc serum and their expression even increased in macrophages stimulated with “Active” and “Late” NVC sera together with the secretion of MMP9. Same results were observed also in cultured THP1-derived macrophages.

Conclusion:

The study confirmed that SSc pts are characterized by a significant increase of circulating M2 cells, suggesting their possible involvement in the pathogenesis of the disease. Interestingly, results insinuate that sera from SSc patients already in an “Early” NVC condition (sera known to contains specific profibrotic molecules such as cytokines, growth factors like TGFb1 or endothelin-1) seem able to inducein vitroa profibrotic M2 macrophage phenotype.

References:

[1]Cutolo M et al. ExpRevClin Immunol. 2019;15:753-64.

[2]Stifano G et al. Curr Rheumatol Rep. 2016; 18:2. doi: 10.1007/s11926-015-0554-8.

[3]Medeiros NI et al. Parasite Immunol. 2017;39: doi: 10.1111/pim.12446.

Disclosure of Interests:

Stefano Soldano: None declared, Samuele Tardito: None declared, Sabrina Paolino: None declared, Massimo Patanè: None declared, Emanuele Gotelli: None declared, Claudio Corallo: None declared, Carmen Pizzorni: None declared, Greta Pacini: None declared, Federica Goegan: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci, Carlotta Schenone: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha

AB0168 NINTEDANIB (TYROSINE-KINASE INHIBITOR) INHIBITS THE TRANSITION OF CIRCULATING FIBROCYTES ISOLATED FROM SYSTEMIC SCLEROSIS PATIENTS INTO MYOFIBROBLASTS: AN IN VITROSTUDY

Background:

Systemic sclerosis (SSc) is a chronic connective disease characterized by microvascular alterations, dysregulated immune response and fibrosis [1,2]. Myofibroblasts are alpha-smooth muscle actin (alphaSMA)+cells and play a crucial role in fibrosis, through the excessive synthesis and deposition of extracellular matrix (ECM) proteins, in particular fibronectin (FN) and type I collagen (COL1) [3]. Despite myofibroblasts primarily derive from resident fibroblasts transition and differentiation, another important source is represented by circulating fibrocytes [4]. Nintedanib is a tyrosine kinase inhibitor approved for the treatment of idiopathic pulmonary fibrosis that interferes with the signalling pathways involved in the pathogenesis of fibrosis [5].

Objectives:

To investigate the possible effects of nintedanib in contrasting the ability of cultured mature fibrocytes from SSc patients to differentiate into profibrotic myofibroblasts.

Methods:

Circulating fibrocytes were obtained from peripheral blood mononuclear cells isolated from 5 limited cutaneous SSc patients (mean age 68 +/- 10 years) and then plated on FN-coated tissue culture dishes in growth medium (DMEM at 20% of fetal bovine serum, 1% of penicillin-streptomycin and 1% L-glutamine), to allow the adhesion of fibrocyte precursors. Adherent cells were maintained in growth medium for 8 days in order to allow their differentiation into fibrocytes. Differentiated fibrocytes were treated with nintedanib at the concentrations of 100nM and 1000nM for 3 and 24 hours (hrs) or maintained in growth medium without any treatment. The differentiation of fibrocytes into myofibroblasts was determined evaluating the gene expression of alphaSMA, fibroblast specific protein-1 (S100A4) COL1, FN and CXCR4 by quantitative real-time polymerase chain reaction, and the protein synthesis of alphaSMA, COL1 and FN by western blotting.

Results:

Nintedanib inhibited alphaSMA and S100A4 gene expression already at the concentration of 100nM in cultured fibrocytes and after 3 hrs of treatment, when compared with untreated cells. Furthermore, both concentrations of nintedanib (100nM and 1000nM) reduced the gene expression of COL1 and FN, whereas only 100nM downregulated the CXCR4 gene expression. At protein level, nintedanib 100nM and 1000nM reduced the synthesis of alphaSMA and COL1 after 24 hrs of treatment, whereas FN synthesis was reduced only by the nintedanib concentration of 1000nM.

Conclusion:

The preliminary results show that nintedanib may inhibit thein vitrotransition of SSc fibrocytes into myofibroblasts and their profibrotic activity, through the reduction of specific myofibroblast phenotype markers and ECM protein production. The results seem to suggest fibrocytes as further possible target of the antifibrotic action of nintedanib in SSc.

References:

[1]Cutolo M et al. Expert Rev Clin Immunol. 2019;15:753-64 2. Barsotti S et al. Clin Exp Rheumatol. 2016;34(Suppl.100):S3-S13 3. Wynn TA et al. Nat Med. 2012;18:1028-40. 4.Distler JHW et al. Arthritis Rheumatol. 2017;69:257-67 5.Hilberg F et al. Cancer Res. 2008;68:4774-82.

Disclosure of Interests:

Stefano Soldano: None declared, Giulia Martinelli: None declared, Samuele Tardito: None declared, Sabrina Paolino: None declared, Massimo Patanè: None declared, Emanuele Gotelli: None declared, Claudio Corallo: None declared, Carmen Pizzorni: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci, Carlotta Schenone: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha

SAT0337 EVALUATION OF BODY COMPOSITION AND BONE STATUS ACCORDING TO MICROVASCULAR INVOLVEMENT IN SYSTEMIC SCLEROSIS PATIENTS

Background:

Systemic sclerosis (SSc) is a complex autoimmune connective tissue disease, characterized by autoimmune inflammatory microvascular damage with progressive loss of capillaries, fibrosis and ischemia of skin and internal organs. (1) Nailfold videocapillaroscopy (NVC) is a safe toll for early diagnosis of SSc, it identify morphological changes of vessel that are predictive for clinical disease progression and organ involvement.(2) About clinical complication the loss of bone mass and body composition abnormalities, particularly muscle mass and strength loss (sarcopenia), are recognized in advanced disease.(3)

Objectives:

To evaluated in SSc patients, the body composition and the bone status according to the microvascular condition, assessed and scored by nailfold videocapillaroscopy (NVC, “Early”,”Active”,”Late” patterns).

Methods:

Body composition and bone mineral density (BMD) were assessed by DEXA in 35 female SSc patients classified according to the 2013 EULAR/ACR criteria and 32 sex-matched healthy subjects. Clinical, laboratory, body composition and bone parameters were analysed according to the different NVC patterns. Means were compared by the Student’s t test or one way analysis of variance; medians were compared by the Kruskall Wallis test; and frequencies by the chi square test.

Results:

Higher prevalence of vertebral (26.4%vs 9.3%) and femoral (32.3% vs 9.3%) osteoporosis (OP) was found in SSc. Particularly SSc patients with “Late” NVC pattern showed a significantly higher prevalence of vertebral (p=0.018) and femoral OP (p=0.016). Regional assessment of bone mass (BM) in 7 different body areas showed a significant lower BMD only at the total spine (P=0.008) and femoral neck (p=0.027) in advanced microvascular damage. Patients with “Late” NVC pattern showed lower whole body lean mass (LM) compared to “Early” and “Active” NVC patterns, particularly at upper limbs. To note, in all body sites, BMD correlate with LM and BMC according to NVC pattern severity.

Conclusion:

SSc patients with most severe microvascular damage show a significantly altered body composition and bone status suggesting a strong link between microvascular failure and associated muscle/bone sufference.

References:

[1]Cutolo M et al. Expert Rev Clin Immunol 2019; 15(7):753-64

[2]Cutolo M et al. Clin Rheumatol 2019; 38(9):2293-7

[3]Corallo C et al. Rheumatol Int 2019;39(10):1767-75.

Disclosure of Interests:

Sabrina Paolino: None declared, Emanuele Gotelli: None declared, Andrea Casabella: None declared, Francesco Cattelan: None declared, Carlotta Schenone: None declared, Massimo Patanè: None declared, Greta Pacini: None declared, Carmen Pizzorni: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha

SAT0301 CIRCULATING FIBROCYTES FROM SYSTEMIC SCLEROSIS PATIENTS AS POSSIBLE TARGET OF CTLA4-IG TREATMENT: AN IN VITRO STUDY

Background:

muscle actin (aSMA)+cells involved in the overproduction of extracellular matrix proteins, primarily fibronectin (FN) and type I collagen (COL1) at the level of damaged tissues (1). These cells may originate from different cell types including fibroblasts, endothelial and epithelial cells, and fibrocytes (1). Circulating fibrocytes are bone marrow progenitor cells expressing specific markers of hematopoietic (CD34, CD45, and MHC class II) and stromal cells (COL1 and COL3), chemokine receptors (CCR2, CCR7), and CXCR4 (2). CXCR4 regulates fibrocyte migration into injured tissues allowing their differentiation into fibroblasts/myofibroblasts (2).

In vitro, fibrocytes differentiate from circulating CD14+monocytes showing an antigen-presenting capability through the expression of HLA-DR and costimulatory molecule CD86 (2). CTLA4-Ig fusion protein (abatacept) interacts with CD86 on cell surface of antigen presenting cells (APCs), such as macrophages and endothelial cells (3,4).

Objectives:

To investigate the possible effect of CTLA4-Ig treatment on cultured human fibrocytes and skin fibroblasts isolated from the same systemic sclerosis patients (SSc pts).

Methods:

Fibrocytes isolated from the peripheral blood mononuclear cells of SSc pts and healthy subjects (HSs) were cultured on fibronectin-coated plates in DMEM at 20% of FBS; for further 8 days (T8) to allow their complete differentiation. Differentiated fibrocytes were maintained in growth medium or treated with CTLA4-Ig at different concentrations (10, 50, 100, and 500μg/ml) for 3 hours. Fibroblasts were isolated from the skin biopsies of the same patients and HSs, cultured until the 3rdpassage in RPMI at 10% FBS and then treated with CTLA4-Ig for 24 and 48 hours. Fibrocytes were characterized as CD45+CXCR4+COL1+cells and the expression of CD86 and HLA-DR was also evaluated. The gene expression of aSMA, COL1, CXCR4, TGFb1 and CD86 was investigated by quantitative real-time polymerase chain reaction in cultured fibrocytes and skin fibroblasts. In cultured skin fibroblasts, COL1 and fibronectin synthesis was evaluated by Western blotting.

Results:

Treatment with CTLA4-Ig for 3 hours significantly downregulated aSMA and COL1 gene expression in cultured SSc fibrocytes at T8 (p<0.01, p<0.05 vs. untreated fibrocytes), whereas no modulatory effect was observed on the TGFbeta1 and CXCR4 gene expression. In cultured SSc skin fibroblasts, CTLA4-Ig did not induce any significant effect on CD68, TGFb1, COL1 and FN gene expression as well as COL1 and FN protein synthesis, both after 24 and 48 hours. Of note, these cultured SSc skin fibroblasts showed a low expression of CD86.

Conclusion:

Due to their high expression of CD86, circulating fibrocytes seem to be more responsive to CTLA4-Ig treatment than the skin fibroblasts isolated from the same SSc patient.

References:

[1]Cutolo M et al. Expert Rev Clin Immunol. 2019;15:753-64.

[2]Bucala R. Mol Med.2015;2:S3-5.

[3]Cutolo M et al. Clin Exp Rheumatol. 2015;33:250-4.

[4]Brizzolara R et al. J Rheumatol. 2013;40:738-40.

Disclosure of Interests:

Stefano Soldano: None declared, Paola Montagna: None declared, Sabrina Paolino: None declared, Elisa Alessandri: None declared, Carmen Pizzorni: None declared, Greta Pacini: None declared, Federica Goegan: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci, Carlotta Schenone: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Maurizio Cutolo Grant/research support from: Bristol-Myers Squibb, Actelion, Celgene, Consultant of: Bristol-Myers Squibb, Speakers bureau: Sigma-Alpha