Imaging Findings in Patients with Immune Checkpoint Inhibitor-Induced Arthritis

Immune checkpoint inhibitor (ICI)-induced arthritis is an increasingly recognized adverse event in patients with oncologic disease during immunotherapy. Four patterns are well described, including rheumatoid arthritis (RA)-like, polymyalgia rheumatica (PMR)-like, psoriatic arthritis (PsA)-like, and oligo-monoarthritis, among others. Despite better clinical recognition of these syndromes, information about the main imaging findings is limited.

METHODS

We conducted a retrospective observational study including all adult patients referred to the Rheumatology Department of a single-center due to ICI-induced arthritis who underwent imaging studies [ultrasound (US), magnetic resonance imaging (MRI), and 18F-FDG PET/CT)] between January 2017 and January 2022.

RESULTS

Nineteen patients with ICI-induced arthritis with at least one diagnostic imaging assessment were identified (15 US, 4 MRI, 2 18F-FDG PET/CT). Most patients were male (84.2%), with a median age at inclusion of 73 years. The main underlying diagnoses for ICI treatment were melanoma in five cases. The distribution of ICI-induced arthritis was as follows: PMR-like (5, 26.2%), RA-like (4, 21.1%), PsA-like (4, 21.1%), and others (6, 31.6%). All RA-like patients had US findings indistinguishable from conventional RA patients. In addition, 3/5 (60%) of PMR-like patients had significant involvement of the hands and wrists. Abnormal findings on MRI or PET-CT were reported by clinical symptoms. No erosions or myofascitis were seen.

CONCLUSIONS

ICI-induced arthritis patients present inflammatory patterns on imaging studies similar to conventional inflammatory arthropathies, and therefore these syndromes should be followed carefully and treated according to these findings.

High Sensitivity C Reactive Protein in Patients with Rheumatoid Arthritis Treated with Antibodies against IL-6 or Jak Inhibitors: A Clinical and Ultrasonographic Study

Background: We examined whether high-sensitivity CRP (hsCRP) reflected the inflammatory disease status evaluated by clinical and ultrasound (US) parameters in RA patients receiving IL-6 receptor antibodies (anti-IL-6R) or JAK inhibitors (JAKi). Methods: We conducted a cross-sectional study of patients with established RA receiving anti-IL-6R (tocilizumab, sarilumab) or JAKi (tofacitinib, baricitinib). Serum hsCRP and US synovitis in both hands were measured. Associations between hsCRP and clinical inflammatory activity were evaluated using composite activity indices. The association between hsCRP and US synovitis was analyzed. Results: 63 (92% female) patients (42 anti- IL-6R and 21 JAKi) were included, and the median disease duration was 14.4 (0.2–37.5) years. Most patients were in remission or had low levels of disease. Overall hsCRP values were very low, and significantly lower in anti-IL-6R patients (median 0.04 mg/dL vs. 0.16 mg/dL). Anti-IL-6R (82.4%) patients and 48% of JAKi patients had very low hsCRP levels (≤0.1 mg/dL) (p = 0.002). In the anti-IL-6R group, hsCRP did not correlate with the composite activity index or US synovitis. In the JAKi group, hsCRP moderately correlated with US parameters (r = 0.5) but not clinical disease activity, and hsCRP levels were higher in patients with US synovitis (0.02 vs. 0.42 mg/dL) (p = 0.001). Conclusion: In anti-IL-6R RA-treated patients, hsCRP does not reflect the inflammatory disease state, but in those treated with JAKi, hsCRP was associated with US synovitis.

Calprotectin in Patients with Rheumatic Immunomediated Adverse Effects Induced by Checkpoints Inhibitors

BACKGROUND

this is an exploratory study to evaluate calprotectin serum levels in patients with rheumatic immune-related adverse events (irAEs) induced by immune checkpoint inhibitor (ICI) treatment.

METHODS

this is a retrospective observational study including patients with irAEs rheumatic syndromes. We compared the calprotectin levels to those in a control group of patients with RA and with a control group of healthy individuals. Additionally, we included a control group of patients treated with ICI but without irAEs to check calprotectin levels. We also analysed the performance of calprotectin for the identification of active rheumatic disease using receiver operating characteristic curves (ROC).

RESULTS

18 patients with rheumatic irAEs were compared to a control group of 128 RA patients and another group of 29 healthy donors. The mean calprotectin level in the irAE group was 5.15 μg/mL, which was higher than the levels in both the RA group (3.19 μg/mL) and the healthy group (3.81 μg/mL) (cut-off 2 μg/mL). Additionally, 8 oncology patients without irAEs were included. In this group, calprotectin levels were similar to those of the healthy controls. In patients with active inflammation, the calprotectin levels in the irAE group were significantly higher (8.43 μg/mL) compared to the RA group (3.94 μg/mL). ROC curve analysis showed that calprotectin had a very good discriminatory capacity to identify inflammatory activity in patients with rheumatic irAEs (AUC of 0.864).

CONCLUSIONS

the results suggest that calprotectin may serve as a marker of inflammatory activity in patients with rheumatic irAEs induced by treatment with ICIs.

POS1474-HPR FATIGUE IS AN IMPORTANT COMORBIDITY FOR RA PATIENTS. HOW CAN WE MEASURE IT EASILY IN CLINICAL PRACTICE?

Background

Fatigue is highly prevalent (40-70%) in Rheumatoid Arthritis (RA)1. Patients describe fatigue as an important symptom, in discrepancy with rheumatologist´s perception. Different validated questionnaires are available to measure fatigue, without any standarised preference in their use. In randomized controlled trials, FACIT-F is a unidimensional tool for fatigue widely used. MDHAQ is a multidimensional tool exploring different dimensions of RA, providing a VAS 0-10 for fatigue as a simple scale to measure it2.

Objectives

We studied fatigue in RA patients with two different questionnaires, FACIT-F and VAS 0-10 included in MDHAQ, and evaluated their utility in clinical practice.

Methods

Patients with RA (ACR/EULAR criteria, 2010) who agreed to participate in this study were included consecutively in the Arthritis Unit for 3 months. They fulfilled 2 questionnaires to evaluate fatigue: 1. FACIT-F(FS)=FACIT-Fatigue, 13 questions (0-4 score) with a global score of 0-52 (lower scores indicate worse fatigue). 2. VAS 0-10 of fatigue (=VAS-Fatigue) included in the question 9 in MDHAQ. Other self-reported queries of the MDHAQ were collected: 1-10 physical function (FN) according to modified HAQ (0-10), VAS 1-10 for pain (PN) and patient global assessment (PATGL) to calculate RAPID3, a review of 60 symptoms (ROS60) and self-assessment 48 joint count (RADAI48). Physical articular examination (TJC 0-28, SJC 0-28), laboratory test (CRP, ESR), composite EULAR disease activity indices (DAS28-ESR, SDAI), demographic (sex, age, BMI) and patient´s disease characteristics, also screened for depression with Patient Health Questionnaire 9= PHQ9≥10) were collected.

A descriptive analysis of the variables was done, and Pearson´s correlation between FACIT-Fatigue and VAS-Fatigue scores, and between each questionnaire (FACIT-Fatigue and VAS-Fatigue) and the rest of variables was performed.

Results

A total of 75 patients (84% females) with RA were recruited, with a mean age of 62 (±11.6) years, a mean disease duration of 14.6 (± 5) years, a mean BMI of 22.8 (± 8.0), 64% with bDMARD and 45.3% with glucocorticoids treatment. Depression (PHQ9≥10) was observed in 16%. Correlation between the two studied questionnaires (FACIT-Fatigue and VAS-Fatigue) was almost very good (-0.79, p<0.001). Statistically significant (p<0.05) similar correlation ~0.70 were obtained between VAS-Fatigue (range: 0.60, 0.76) and ~0.80 between FACIT-Fatigue (range:-0.70,-0.87) and self-reported MDHAQ queries (FN, PN, PATGL, RAPID3, ROS60, and RADAI48). Similar but moderate correlation~0.50 (range:0.42,-0.61) was obtained in both questionnaires with TJC and EULAR indices of disease activity (DAS28-ESR, SDAI), and similar but lower ~0.20 (range:0.24, -0.29) with inflammatory variables (CRP, ESR, SJC) except for ESR and FACIT-Fatigue, no correlation was observed. Depression (PHQ9≥10) obtained the highest correlation with -0.92, p<0.001 in FACIT-Fatigue, and less for VAS-Fatigue 0.66, p<0.001 (Table 1).

Table 1.

Correlation between VAS-Fatigue and FACIT-Fatigue and the different disease activity variables.

VAS-Fatigue (0-10)p-valueFACIT- Fatigue (0-52)p-valueFACIT-Fatigue (0-52)-0.79<0.0011VAS-Fatigue (0-10)1-0.79TJC (0-28)0.42<0.001-0.58<0.001SJC (0-28)0.240.040-0.290.014CRP0.270.021-0.280.017ESR0.250.032-0.200.096DAS28-ESR0.52<0.001-0.61<0.001SDAI (0-86)0.49<0.001-0.58<0.001FN (0-10)0.76<0.001-0.87<0.001PN (0-10)0.70<0.001-0.62<0.001PATGL (0-10)0.75<0.001-0.73<0.001RAPID3 (0-30)0.77<0.001-0.75<0.001ROS60 (0-60)0.66<0.001-0.77<0.001RADAI48 (0-48)0.60<0.001-0.70<0.001PHQ9 (0-27)0.66<0.001-0.92<0.001

Conclusion

VAS (1-10) is a good tool compared to FACIT to easily measure of fatigue in daily routine for RA patients. The use of this simple scale integrated in the MDHAQ allows capturing important clinical information for the disease.

References

[1]Hewlett S, et al. Rheumatology 2011;50:1004-6. 2. Hewlett S, et al. Arthritis Care Res 2011; 63: S263-86.

Disclosure of Interests

Beatriz Frade-Sosa: None declared, Rosa Morlà: None declared, Nuria Sapena: None declared, Raimón Sanmartí Speakers bureau: Abbvie, BMS, Gebro-Pharma, Lilly, MSD, Pfizer, Sanofi, Roche, José A Gómez-Puerta Speakers bureau: Abbvie, BMS, Galápagos, GSK, Janssen, MSD, Lilly, Pfizer, Roche, Consultant of: Galapagos, Roche, Sanofi

AB0283 FATIGUE AND DISEASE ACTIVITY IN RHEUMATOID ARTHRITIS. A RESIDUAL FATIGUE OF HIGH LEVEL CAN BE OBSERVED EVEN IN LOW DISEASE ACTIVITY

Background

Fatigue is a major symptom suffered by patients with rheumatoid arthritis (RA), with a high prevalence (40%-70%)1. Different questionnaires and scales (BRAF, FACIT, SF36v, MDHAQ, VAS...) have been validated, but none have been standardized to measure it. In observational studies, the VAS (0-10) scale was reported as a good measure for fatigue; cut-off>5/10 indicates high level2. A residual fatigue in low activity/remission of the disease has been described in a significant proportion of patients3.

Objectives

We studied the association with high level of fatigue and the clinical disease activity in non-selected RA patients.

Methods

RA patients (ACR/EULAR criteria, 2010) were included consecutively in our Arthritis Unit during a period of 3 months. Patients completed 2-pages MDHAQ that includes a VAS 0-10 for fatigue at question 9, in addition to other queries: physical function (FN) + pain (PN) + patient global assessment (PATGL), checklist of 60 symptoms (ROS60) and self-assessment 48 joint count (RADAI48). VAS for Fatigue was calculated with a cut-off point ≥5/10 to obtain the group with high fatigue. Demographic variables (age, sex, BMI) and clinical variables: disease duration, treatment with bDMARDs and glucocorticoids, joint physical examination (TJC 0-28, SJC 0-28), acute phase reactants (ESR, CRP), physician global assessment (PhyGL), and the rates of clinical activity with their respective clinically significant differences (DAS28-ESR>0.6; SDAI>10; RAPID3>3.8) were also calculated.

A descriptive analysis (mean and SD) of all the variables, a bivariate analysis to compare groups (Student t for quantitative and Chi2 tests for categorical variables) and calculation of numerical differences between indices was performed.

Results

A total of 75 RA patients (84% females) were recruited, of mean age of 62 (SD:11.6) years, with media BMI of 22.8 (SD:8.0), mean disease duration of 14.6 (± 5) years, 16% depressed (PHQ9≥10), treated with bDMARD (64%) and glucocorticoids (45,3%). Means of disease clinical indexes were as follows: DAS28-ESR (2.55, SD:1.21), SDAI (8.7, SD:8.00) and RAPID3 (5.97, SD:5.85).

In 31 (41.2%) of patients we observed high fatigue (VAS-fatigue≥5/10). When comparing with those with low or no fatigue levels, these patients have higher disease activity measured by the composite activity indices and acute phase reactants except for the SJC. All self-reported variables evaluated by MDHAQ (FN, PN, RADAI48, ROS60) were also higher in patients with high fatigue levels (Table 1).

Table 1.

Descriptive and comparison variables between groups, expressed as mean and SD.

All patients, n=75Non-high fatiguegroup,n=44 (58.6%)High fatiguegroup, n=31 (41.3%)pvalueTJC (0-28)1,45 (2,81)0,59 (1,21)2,68 (3,84)0.001SJC (0-28)1,23 (2,18)0,96 (1,94)1,63 (2,47)0.200PCR0,7 (0,97)0,47 (0,29)1,02 (1,42)0.014ESR13,9 (15,0)10,52 (9,44)18,68 (19,56)0.019FN (0-10)1,26 (1,82)0,72 (1,23)3,20(2,39)0.004PN (0-10)3,56 (3,12)1,90 (2,28)5,30 (2,98)<0.001PATGL (0-10)3,27 (2,86)2,07 (2,24)5,18 (2,77)0.001RADAI48 (0-48)7,85 (8,81)4,14 (5,50)12,87 (9,99)<0.001ROS60 (0-60)10,06 (8,84)5,78(5,03)15,71 (9,64)<0.001PhyGL (0-10)2,43 (1,94)1,90 (1,47)3, 18 (3,27)0.004DAS28-ESR2,55 (1,21)2,13 (0,97)3,15 (1,27)0.001SDAI8,7 (8,0)6,18 (4,80)12,33 (10,01)0.001RAPID3 (0-30)5,97 (5,85)3,08 (3,48)10,29(0,06)<0.001

The mean differences in the three activity indices between both groups were statistically significant, in the DAS28-ESR and RAPID3 were also considered clinically relevant: 1.02 (>0.6) and 7.2 (>3.8) respectively, but not for SDAI: 6.15 (>10).

Conclusion

Even non-selected RA patients but with low disease activity, high fatigue level was common. For a better approach to fatigue in RA patients, it would be interesting not to forget this residual fatigue.

References

[1]Hewlett S, et al. Rheumatology 2011;50:1004-6.

[2]Pollard LC, et al. Rheumatology 2006;45:885-9.

[3]Druce K, et al. Rheumatology 2016;5:1786-90.

Disclosure of Interests

Rosa Morlà: None declared, Beatriz Frade-Sosa: None declared, Nuria Sapena: None declared, José A Gómez-Puerta Speakers bureau: Abbvie, BMS, Galápagos, GSK, Janssen, MSD, Lilly, Pfizer, Roche, Consultant of: Galapagos, Roche, Sanofi, Raimón Sanmartí Speakers bureau: Abbvie, BMS, Gebro-Pharma, Lilly, MSD, Pfizer, Sanofi, Roche

Satisfaction and effectiveness of switching from intravenous to subcutaneous belimumab treatment in daily clinical practice

BACKGROUND

In 2017, belimumab (BEL) was approved in subcutaneous (SQ) administration. The effectiveness after switching from intravenous (IV) to SQ and patient satisfaction in daily clinical practice has not been studied. During the pandemic, patient follow-up and treatment were significantly affected, and some patients need a change from IV to SQ. Our aim was to evaluate daily clinical practice satisfaction to SQ BEL therapy in patients previously treated IV BEL. We hypothesized that SQ BEL in SLE patients previously treated with IV BEL was similar in effectiveness and conferred higher satisfaction.

METHODS

Observational, multicenter study, conducted in 7 reference centers in Catalonia. We included stable SLE patients (EULAR/ACR 2019) on treatment with SQ BEL and previous use of IV BEL (at least 3 months on IV BEL before switching). Since there are no well-validated tools for SQ BEL treatment satisfaction, we used RASQ-SQ, validated in patients with lymphoma who switched from IV Rituximab to SQ treatment, and modified for BEL treatment.

RESULTS

Twenty-seven patients were included. The more prevalent clinical manifestations observed were related to the skin and joints and the patients had a mean baseline SLEDAI of 2.96 (SD 2.4) and SLICC score of 0.67 (SD 0.88). The median time from treatment with IV BEL before switching to SQ was 21 months (range). 84% of patients reported confidence in SQ BEL. 85.2% felt that treatment with SQ BEL was convenient or very convenient. 85% felt they had gained time with the change. 89% would recommend the SQ injection to other patients. Disease activity (mean SLEDAI) and remission rates remain stable after switching. No major new adverse effects were reported.

CONCLUSIONS

Overall satisfaction, satisfaction with via of administration, and satisfaction with the time taken to receive BEL were higher for SQ BEL treatment. A switching SQ strategy is a reasonable alternative for BEL patients.

Neutrophilic Activity Biomarkers (Plasma Neutrophil Extracellular Traps and Calprotectin) in Established Patients with Rheumatoid Arthritis Receiving Biological or JAK Inhibitors: A Clinical and Ultrasonographic Study

INTRODUCTION

This study assesses the accuracy of neutrophil activation markers, including neutrophil extracellular traps (NETs) and calprotectin, as biomarkers of disease activity in patients with established rheumatoid arthritis (RA). We also analyse the relationship between NETs and various types of therapies as well as their association with autoimmunity.

METHODS

Observational cross-sectional study of patients with RA receiving treatment with biological disease-modifying antirheumatic drugs or Janus kinase inhibitors (JAK-inhibitors) for at least 3 months. Plasma calprotectin levels were measured using an enzyme-linked immunosorbent assay test kit and NETs by measuring their remnants in plasma (neutrophil elastase-DNA and histone-DNA complexes). We also assessed clinical disease activity, joint ultrasound findings and autoantibody status [reumatoid factor (RF), anti-citrullinated peptide/protein antibodies (ACPAs) and anti-carbamylated protein (anti-CarP)]. Associations between neutrophilic biomarkers and clinical or ultrasound scores were sought using correlation analysis. The discriminatory capacity of both neutrophilic biomarkers to detect ultrasound synovitis was analysed through receiver-operating characteristic (ROC) curves.

RESULTS

One hundred fourteen patients were included. Two control groups were included to compare NET levels. The active control group consisted of 15 patients. The second control group consisted of 30 healthy subjects. Plasma NET levels did not correlate with clinical disease status, regardless of the clinic index analysed or the biological therapy administered. No significant correlation was observed between NET remnants and ultrasound synovitis. There was no correlation between plasma NET and autoantibodies. In contrast, plasma calprotectin positively correlated with clinical parameters (swollen joint count [SJC] rho = 0.49; P < 0.001, Clinical Disease Activity Index [CDAI] rho = 0.30; P < 0.001) and ultrasound parameters (rho > 0.50; P < 0.001). Notably, this correlation was stronger than that observed with acute phase reactants.

CONCLUSION

While NET formation induced by neutrophils may play a role in RA pathogenesis, our study raises questions about the utility of NET remnants in peripheral circulation as a biomarker for inflammatory activity. In contrast, this study strongly supports the usefulness of calprotectin as a biomarker of inflammatory activity in patients with RA.