Cyclophosphamide vs rituximab for eradicating inhibitors in acquired hemophilia A: A randomized trial in 108 patients

BACKGROUND

Acquired hemophilia A (AHA) is a rare autoimmune disorder due to autoantibodies against Factor VIII, with a high mortality risk. Treatments aim to control bleeding and eradicate antibodies by immunosuppression. International recommendations rely on registers and international expert panels.

METHODS

CREHA, an open-label randomized trial, compared the efficacy and safety of cyclophosphamide and rituximab in association with steroids in patients with newly diagnosed AHA. Participants were treated with 1 mg/kg prednisone daily and randomly assigned to receive either 1.5-2 mg/kg/day cyclophosphamide orally for 6 weeks, or 375 mg/m2 rituximab once weekly for 4 weeks. The primary endpoint was complete remission over 18 months. Secondary endpoints included time to achieve complete remission, relapse occurrence, mortality, infections and bleeding, and severe adverse events.

RESULTS

Recruitment was interrupted because of new treatment recommendations after 108 patients included (58 cyclophosphamide, 50 rituximab). After 18 months, 39 cyclophosphamide patients (67.2 %) and 31 rituximab patients (62.0 %) were in complete remission (OR 1.26; 95 % CI, 0.57 to 2.78). In the poor prognosis group (FVIII < 1 IU/dL, inhibitor titer > 20 BU mL-1), significantly more remissions were observed with cyclophosphamide (22 patients, 78.6 %) than with rituximab (12 patients, 48.0 %; p = 0.02). Relapse rates, deaths, severe infections, and bleeding were similar in the 2 groups. In patients with severe infection, cumulative doses of steroids were significantly higher than in patients without infection (p = 0.03).

CONCLUSION

Cyclophosphamide and rituximab showed similar efficacy and safety. As first line, cyclophosphamide seems preferable, especially in poor prognosis patients, as administered orally and less expensive.

FUNDING

French Ministry of Health.

CLINICALTRIALS

gov number: NCT01808911.

French national diagnostic and care protocol for Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis with a particular tropism for the coronary arteries. KD mainly affects male children between 6 months and 5 years of age. The diagnosis is clinical, based on the international American Heart Association criteria. It should be systematically considered in children with a fever, either of 5 days or more, or of 3 days if all other criteria are present. It is important to note that most children present with marked irritability and may have digestive signs. Although the biological inflammatory response is not specific, it is of great value for the diagnosis. Because of the difficulty of recognising incomplete or atypical forms of KD, and the need for urgent treatment, the child should be referred to a paediatric hospital as soon as the diagnosis is suspected. In the event of signs of heart failure (pallor, tachycardia, polypnea, sweating, hepatomegaly, unstable blood pressure), medical transfer to an intensive care unit (ICU) is essential. The standard treatment is an infusion of IVIG combined with aspirin (before 10 days of fever, and for a minimum of 6 weeks), which reduces the risk of coronary aneurysms. In case of coronary involvement, antiplatelet therapy can be maintained for life. In case of a giant aneurysm, anticoagulant treatment is added to the antiplatelet agent. The prognosis of KD is generally good and most children recover without sequelae. The prognosis in children with initial coronary involvement depends on the progression of the cardiac anomalies, which are monitored during careful specialised cardiological follow-up.

[Hereditary angioedema and its new treatments: An update]

Hereditary angioedema, with or without deficient C1 inhibitor level or function, is a rare disease characterized by recurrent attacks of noninflammatory subcutaneous and/or submucosal edema. It may be life-threatening and substantially affects quality of life. Attacks may be spontaneous or induced, in a setting of emotional stress, by infections or physical trauma, in particular. As the key mediator is bradykinin, this angioedema does not respond to the usual treatments of mast cell-mediated angioedema (antihistamines, corticosteroids, adrenaline), which is much more frequent. Therapeutic management of hereditary angioedema first consists in treating severe attacks with a selective B2 bradykinin receptor antagonist or a C1 inhibitor concentrate. The latter or an attenuated androgen (danazol) can be used for short-term prophylaxis. Therapeutic solutions conventionally proposed for long-term prophylaxis (danazol, antifibrinolytics [tranexamic acid], C1 inhibitor concentrate) vary in efficacy and/or pose problems of safety or ease of use. Kallikrein inhibitors (subcutaneous lanadelumab, oral berotralstat) recently made available as disease-modifying treatment constitute an important advance in long-term prophylaxis of hereditary angioedema attacks. The advent of these new drugs is accompanied by a new ambition for patients: optimize control of the disease and thereby minimize its impact on quality of life.

AB0044 REDUCED PERIPHERAL BLOOD MYELOID CELLS IN PATIENTS WITH VEXAS SYNDROME

Background

Systemic inflammatory or dysimmune diseases (SIDDs) are encountered in up to a quarter of patients with myelodysplastic syndromes (MDS). Recently identified VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, associated with somatic mutations in UBA1, encompasses a range of severe inflammatory conditions along with hematologic abnormalities, including myelodysplasia. Only limited data are available on the pathophysiology of MDS-associated SIDDs, and especially about the role of different myeloid cell subsets.

Objectives

The aim of this study was to describe the phenotype of myeloid immune cells (dendritic cells and monocytes) in MDS patients with associated SIDDs, and to compare their distribution with MDS patients without SIDDs and controls.

Methods

Phenotype analysis by flow cytometry from PBMCs of 14 MDS patients with SIDDs, 23 MDS patients without SIDDs and 7 controls without MDS and SIDDs. Eight of the 14 MDS/SIDDs patients (57%) had a somatic UBA1 mutation.

Results

In this study analyzing peripheral blood myeloid immune cells in MDS patients with and without SIDDs, we observed a quantitative reduction of different DC and monocyte subsets in MDS/SIDDs patients, especially in patients with active SIDDs and above all in patients with newly described VEXAS syndrome.

Conclusion

Further functional studies are warranted to better understand the mechanisms and the consequences of the phenotypic modulations of immune myeloid cells in the pathophysiology of MDS-associated SIDDs, especially in VEXAS syndrome.

Disclosure of Interests

None declared

AB0461 TRIPLE POSITIVE PROFILE IN ANTIPHOSPHOLIPID SYNDROME: PROGNOSIS, RELAPSE AND MANAGEMENT FROM A RETROSPECTIVE MULTICENTER STUDY

Background

The antiphospholipid syndrome (APS) is defined by the development of vascular thrombosis, or pregnancy morbidity in the presence of persistent antiphospholipid antibodies (APL). Antinuclear antibodies (ANA) can be detected in primary APS patients without any clinical systemic autoimmune disease. The presence of ANA antibodies could confer a specific phenotype in primary APS.

Objectives

Antiphospholipid syndrome (APS) is defined by the association of thromboembolic and/or obstetrical clinical manifestations and the presence of antiphospholipid antibodies (APL). Patients with all three APL are referred to as triple positive (TP). The objective of our study was to evaluate the impact of the TP profile in a cohort of 204 patients.

Methods

Clinical and biologic data from 195 APS were retrospectively collected. ANA test was considered to be positive when titers were superior or egal to the 1/80 dilution. ANA-positive APS patients did not fulfilled SLE ACR/EULAR classification criteria

Results

204 patients were included in our study, 68 were TP and 136 were single or double positive (NTP). 122 patients (59.8%) had primary APS. 67 patients (32.8%) had obstetrical APS, with a higher rate among TP patients (45.6% versus 26.5%, P=0.010), and 170 patients (83.3%) had thrombotic APS, without difference between TP and NTP patients. TP patients had more placental complications than NTP patients (17.6% versus 2.9%, P=0.001) and more non-criteria events (48.5% versus 25.7%, P=0.002). 97 patients (47.5%) presented at least one relapse, and the relapse rate was significantly higher in TP patients than in NTP patients (63.2% versus 39.7%, P=0.002). Of the relapses, 30 were obstetric and 74 thrombotic, and the rate of obstetric relapses was significantly higher in TP patients. During follow-up, 21 patients (10.3%) died and this rate did not differ between the two groups.

In univariate analysis, TP patients (HR 1.77; 95% CI 1.17-2.68; P=0.007), venous APS (HR 1.74; 95% CI 1.13-2.69; P=0.013), a history of premature birth (HR 2.47; 95% CI 1.24-4.93; P=0.010), and curative anticoagulation (HR 4.91; 95% CI 1.55-15.5; P=0.007) are associated with the risk of relapse. The serological profile was also a factor in relapse: the presence of the anti-β2GP1 antibody (HR 1.70; 95% CI 1.09-2.64; P=0.018) and LA (HR 1.59; 95% CI 1.01-2.50; P=0.046). The non-criteria manifestations of APS are associated with a higher risk of relapse, although not statistically significant (HR 1.49; 95% CI 1.00-2.23; P=0.052).

In multivariate analysis, the TP profile remained associated with a risk of relapse (HR 1.63; 95% CI 1.04-2.55; P=0.031), as well as venous APS (HR 2.05; 95% CI 1.30-3.23; P=0.002), and the antecedent of premature delivery (HR 2.33; 95% CI 1.10-4.92; P=0.027). The risk factors associated with relapse in multivariate analysis are summarized in Figure 1.

Conclusion

The TP profile is associated with a higher risk of relapse and obstetrical complications.

Figure 1.

Disclosure of Interests

None declared

Angioedèmes et médecine d’urgence

Les angioedèmes (AE) sont un motif de recours fréquent aux urgences. Leur morbimortalité n’est pas négligeable compte tenu de l’atteinte fréquente des voies aériennes supérieures. On distingue les AE histaminiques et bradykiniques. Aux urgences, la démarche diagnostique et la conduite à tenir doit être systématique et standardisée afin de ne pas méconnaître un potentiel AE bradykinique. Les AE histaminiques, accompagnés dans la plupart des cas d’une urticaire superficielle, sont de loin les plus fréquents et sont associés parfois à une anaphylaxie, ce qui nécessite alors un traitement par adrénaline immédiat. Ils peuvent être allergiques (médiés par les IgE) et sont alors associés à une anaphylaxie ou non allergiques, et se traduisent cliniquement par une urticaire aiguë ou chronique associée à l’AE. Les AE bradykiniques, d’incidence plus rare, sont également pourvoyeurs de recours aux urgences et particulièrement les AE secondaires aux inhibiteurs de l’enzyme de conversion de l’angiotensine compte tenu de leur importante prescription et de leurs atteintes cliniques de la face, de la langue et du larynx, elles-mêmes pourvoyeuses de recours aux urgences. Les traitements spécifiques d’urgence comprennent principalement l’icatibant et le concentré de C1-inhibiteur. Ils doivent être administrés le plus tôt possible devant l’inefficacité des traitements antiallergiques. Un avis auprès d’un expert du centre de référence pour les AE à kinines peut améliorer les prises en charge en aidant à la démarche diagnostique et en organisant la mise à disposition des traitements spécifiques d’urgence.

Why are people still dying of drug-susceptible TB in Paris in the 21st century?

BACKGROUND: Although the burden of TB is lower in France than in low-income countries, patients continue to die from TB in Paris. Our goal was to describe TB-related deaths and to identify associated risk factors.METHODS: We conducted a retrospective cohort study in two hospitals in Paris between 2013 and 2018. All patients with drug-susceptible TB were included and followed until end of treatment. The primary outcome was death. We performed univariate and multivariate analysis using Cox proportional hazard model.RESULTS: Of the 523 patients included, 362 were men (median age 37 years), of whom 24 patients died (4.5%). The final survival model concluded that age (HR 1.1 for each additional year), not living in one´s own accommodation (HR 5.9), being born in France (HR 8.0), being alcoholic (HR 4.2), having a history of cancer (HR 7.1) or meningeal or miliary TB (HR 8.2) were associated with a higher risk of death.CONCLUSION: The rate of TB-associated death is unacceptably high for a curable disease. To note, patients born in France were much more at risk of death than immigrants. We believe raising awareness among healthcare professionals is a potentially easy and efficient lever for improving care.

Further characterization of clinical and laboratory features occurring in VEXAS syndrome in a large-scale analysis of multicenter case-series of 116 French patients

BACKGROUND

A new autoinflammatory syndrome related to somatic mutations of UBA1 was recently described and called VEXAS syndrome.

OBJECTIVE

To describe clinical characteristics, laboratory findings and outcomes of VEXAS syndrome.

DESIGN

Case-series.

SETTING

Patients referred to a French multicenter registry between November 2020 and May 2021.

PATIENTS

116 patients with VEXAS syndrome.

MEASUREMENTS

Frequency and median of parameters and vital status, from diagnosis to the end of the follow-up.

RESULTS

Main clinical features were skin lesions (83.5%), non-infectious fever (63.6%), weight loss (62%), lung involvement (49.6%), ocular symptoms (38.8%), relapsing chondritis (36.4%), venous thrombosis (34.7%), lymph nodes (33.9%), and arthralgia (27.3%). Hematological disease was present in 58 cases (50%), considered as myelodysplastic syndrome (MDS, n= 58) and monoclonal gammapathy of unknown significance (n=12).UBA1 mutations included p.M41T (44.8%), p.M41V (30.2%), p.M41L (18.1%), and splice mutations (6.9%). After a median follow-up of 3.0 years, 18 patients died (15.5%), from infectious origin (n=9) and MDS progression (n=3). Unsupervised analysis identified 3 clusters: cluster 1 (47%) with mild-to-moderate disease; cluster 2 (16%) with underlying MDS and higher mortality rates; cluster 3 (37%) with constitutional manifestations, higher C-reactive protein levels and less frequent chondritis. Five-year probability of survival was 84.2% in cluster 1, 50.5 % in cluster 2, and 89.6% in cluster 3. UBA1 p.Met41Leu mutation was associated with a better prognosis.

CONCLUSION

VEXAS syndrome displays a large spectrum of organ manifestations and shows different clinical and prognostic profiles. It also raises a potential impact of the identified UBA1 mutation.

OP0068 EFFICACY AND SAFETY OF TNF-Α ANTAGONISTS AND TOCILIZUMAB IN TAKAYASU ARTERITIS: MULTICENTER WORLDWIDE RETROSPECTIVE STUDY OF 209 PATIENTS

Background:

In this large worldwide TAK registry, we report 209 patients treated with TNF-α antagonists and tocilizumab aiming to compare their safety and efficacy, and determine the predictive factors of treatment response and relapse.

Objectives:

To assess safety and efficacy of TNF-α antagonists and tocilizumab in patients with Takayasu arteritis (TAK).

Methods:

We conducted a retrospective multicenter study in referral centers from France, Italy, Spain, Israel, Japan, Tunisia and Russia about biological-targeted therapies in TAK during the period from January 2017 to September 2019 for the data collection.

Results:

Two-hundred nine patients with TAK [median age of 29 years [7-62], and 186 (89%) females] were included. They received either TNF-α antagonists [n=132 (63%) with 172 lines; infliximab (n=109), adalimumab (n=45), golimumab (n=8), certolizumab (n=6) and etanercept (n=5)], or tocilizumab [n=77 (37%) with 121 lines; intravenous and subcutaneous in 95 and 26 cases, respectively]. A complete response at 6 months was evidenced in 101/152 (66%) on TNF-α antagonists and 75/107 (70%) on tocilizumab, respectively. Age ≥ 30 years [OR= 2.09 [1.09; 3.99]] was associated with complete response, whereas vascular signs [0.26 [0.1;0.65]], baseline prednisone ≥ 20 mg/day [0.51 [0.28;0.93]] were negatively associated with the complete response to TNF-α antagonists or tocilizumab. During a median follow-up of 36 months, 103 relapses were noted. Supra-aortic branches and thoracic aorta involvements [HR 2.44 (1.06;5.65) and 3.66 (1.18;11.4), respectively], and systemic signs at baseline [HR 2.01 (1.30;3.11)] were significantly associated with relapse. The cumulative incidence of treatment discontinuation and relapse were similar in TNFα antagonists and tocilizumab. Fifty-eight (20%) adverse effects occurred on biological-targeted therapies of whom 37 (21%) and 21 (17%), (p=0.4) on TNF-α antagonists and tocilizumab, respectively

Conclusion:

This large multicenter study shows high efficacy of biological-targeted treatments in refractory TAK. Efficacy, relapse and drug retention rate were equivalent with TNF-α antagonists and tocilizumab.

Disclosure of Interests:

None declared

Efficacité du Tocilizumab dans la COVID-19 modérée à sévère : une cohorte française exposé-non exposé

Introduction

L’infection par le SARS-CoV-2 peut mener à un syndrome de détresse respiratoire aigu dont la mortalité était estimée à 50 % au début de l’épidémie. Ces formes sévères étant significativement associées à un état d’hyperinflammation, et notamment à un niveau élevé d’interleukine-6, il a été proposé que cibler la voie de signalisation de cette interleukine majoritairement pro-inflammatoire, puisse réduire la mortalité de la COVID-19. Pour autant, un an après le début de la pandémie, la place de ces inhibiteurs, dont le Tocilizumab, un anticorps monoclonal dirigé contre le récepteur de l’interleuline-6, reste à déterminer.

Patients et méthodes

Cohorte exposé-non exposé en vie réelle, monocentrique et menée à l’hôpital Saint-Antoine, Paris, France, avant la mise en place de l’essai randomisé CORIMUNO-TOCI. Etaient inclus les patients de plus de 18 ans qui présentaient une forme modérée à sévère de COVID-19, selon la définition de l’OMS, et qui nécessitaient une oxygéno-requerance ≥ 4 L/min, associée à un syndrome inflammatoire biologique (CRP > 50 mg/L). Etaient exclus les patients qui portaient des contre-indications au Tocilizumab (antécédent de sigmoïdite ou de diverticulite, une cytolyse hépatique supérieure à 5 N, une allergie connue au Tocilizumab, ou une infection bactérienne active.) Par ailleurs, les patients qui étaient transférés en soins intensifs dans les premières 24 h après l’injection de Tocilizumab étaient exclus de notre étude, puisque ils étaient inclus dans une étude qui évaluait le Tocilizumab en réanimation. Les patients du groupe Tocilizumab recevaient une injection de 8 mg/kg (maximum 800 mg) de Tocilizumab associée aux soins courants et les patients du groupe soins courants ne recevaient que les soins courants. Pour assurer la comparabilité des deux groupes nous avons utilisé le score de propension. Notre critère de jugement principal était le délai de sevrage en oxygène. Les critères de jugement secondaire étaient : le transfert en soins intensifs, le besoin de ventilation mécanique, le décès toutes causes confondues, le décès au dixi^e jour, la durée d’hospitalisation ainsi que les scores composites intubation ou décès et transfert en soins intensifs ou décès.

Résultats

Cinquante patients ont été inclus dans le groupe Tocilizumab et 52 patients dans le groupe soins courants. L’âge moyen était de 68,9 ± 2 ans et 71 % des patients étaient des hommes. Les patients du groupe Tocilizumab étaient plus fréquemment diabétique (34 % vs 13 % ; p = 0,02), et avaient un niveau d’oxygène moyen plus élevé (9,1 L/min vs 6,8 L/min ; p = 0,0002). Les patients du groupe Tocilizumab avaient reçu plus de corticoïdes que les patients du groupe soins courants (53 % vs 6 % ; p < 0,0001). Le délai de sevrage en oxygène n’était pas diffèrent dans les deux groupes, 14,1 [IQR 7-19] jours dans le groupe Tocilizumab versus 12,2 [IQR 7,5-14] jours dans le groupe soins courants, hazard ratio ajusté à 1,53 (IC95 % (0,96-2,45) ; p = 0,073). Il n’y avait pas non plus de différence concernant les critères de jugement secondaires.

Discussion

Dans cet essai, nous rapportons une absence de bénéfice du Tocilizumab dans les formes modérées à sévères de la COVID-19. L’injection de Tocilizumab à la posologie de 8 mg/kg n’améliorait pas le délai de sevrage en oxygène, et ne réduisait pas la nécessité d’intubation, de transfert en soins intensifs ou la mortalité. Cette absence de différence peut être expliquée, en partie, par le fait que les patients du groupe Tocilizumab étaient plus graves (oxygéno-requerance plus élevée) et comorbides (plus fréquemment diabétiques). En revanche, ces patients avaient reçu plus de corticoides qui est aujourd’hui un traitement recommandé dans la prise en charge des patients sous oxygène, atteints de la COVID-19. Notre étude manque aussi de puissance, une récente méta-analyse estimait à 2300 patients (dans chaque bras) le nombre de sujet nécessaire pour mettre en évidence une différence significative si celle-ci existait.

Conclusion

Un essai randomisé récent qui incluait un nombre de sujet suffisant, en cours de publication, a montré des résultats encourageants, avec une diminution de la mortalité à 28 jours chez les patients traités par Tocilizumab (majoritairement en associations au corticoïdes). Toutefois la question du meilleur moment de l’injection de Tocilizumab chez les patients atteints de COVID-19 reste entière.

[Behçet's-like syndrome and other dysimmunitary manifestations related to myelodysplastic syndromes with trisomy 8]

Myelodysplastic syndromes (MDS) are clonal hematopoietic malignancies which are also characterised by immune dysregulation. The impaired immune response is mainly due to T lymphocytes (CD8 and T regulatory cells) with increased cell apoptosis. MDS could be associated in some cases with various clinical dysimmune features; however, only MDS with trisomy 8 is correlated with particular clinical phenotype. The latter is mainly Behçet's-like disease which includes orogenital aphtosis, skin features and severe ulcerative digestive disease of ileocaecal distribution. Other clinical manifestations, such as arthritis or neutrophilic dermatosis, have been also described in MDS patients with trisomy 8. The dysimmune manifestations, and among them the Behçet's-like disease, do not impact the overall survival or the risk of progression to acute myeloid leukemia. Immunosuppressive and immunomodulatory therapies, and among them TNF-α inhibitors, are usually ineffective to control the dysimmune manifestations. Targeting the underlying clonal disease with specific therapies, such as azacitidine, seems to be the best strategy to control these disorders, even in MDS patients with low-risk disease.

[Periodic fever syndrome associated with mutations in the TNF type 1 receptor gene: A differential diagnosis of familial Mediterranean fever that should not be overlooked in patients of Mediterranean origin]

INTRODUCTION

Tumor Necrosis Factor Type 1 Receptor Associated Periodic Syndrome (TRAPS) is a rare autosomal dominant autosomal autoinflammatory disease associated with mutations in the TNF type 1 receptor gene (TNFRSF1A). It is characterized by relatively long recurrent febrile seizures with an average duration of 7 days accompanied by arthralgia, myalgia, and usually a rash. In a patient of Mediterranean origin with recurrent fever, familial Mediterranean fever is the first diagnosis to be suspected by argument of frequency.

METHODS

A retrospective observational study was conducted on patients from Mediterranean origin followed for TRAPS and included in the "Juvenile Inflammatory Rheumatism" (JIR) observational cohort in the national French autoinflammatory center. The age of onset of symptoms, age of diagnosis, number of years of wandering and treatments received were collected for each index case.

RESULTS

Nine patients from 6 families of Mediterranean origin were included. A molecular diagnosis confirmed TRAPS in all patients. The median age at diagnosis was 26 years, the mean number of years of wandering was 17 years. The diagnosis of FMF was made first in all patients. AA amyloidosis revealed TRAPS in 2 patients. Colchicine was started without any efficacy in all cases. Five patients were treated with interleukin-1 inhibitory biotherapy with 100% efficacy.

CONCLUSION

In a patient of Mediterranean origin presenting with recurrent febrile abdominal pain of AA amyloidosis, the first diagnosis to be suspected is FMF. Long relapses, dominant transmission, a non-Mediterranean relative, and the ineffectiveness of colchicine should evoke TRAPS.

Syndrome de Cogan

"Typical" Cogan's syndrome is defined as a non-syphilitic interstitial keratitis associated with audio-vestibular resembling Ménière's disease with a 2-year maximum delay between these 2 organ impairment. Cogan syndrome is classified as "atypical" in the absence of interstitial keratitis and the presence of other inflammatory eye manifestations, an audio-vestibular impairment different from typical Menière-like disease, or a delay longer than 2 years between eye and audio-vestibular manifestations. Constitutional signs and large-vessel vasculitis is also possible, mostly affecting the thoracic aorta. The presence of acute-phase reactants is common, but no specific laboratory tests are available. The prognosis is dominated by the audio-vestibular impairment and in particular the risk of deafness, while other complications especially vascular complications being rare. Treatment with glucocorticoids is usually necessary and the combination to other immunosuppressive therapies or biological-targeted drugs needs to be determined.

THU0312 AUTOLOGOUS NON-MYELOABLATIVE HEMATOPOIETIC STEM CELL TRANSPLANTATION FOR REFRACTORY TAKAYASU ARTERITIS: A RETROSPECTIVE MULTICENTRE CASE-SERIES FROM THE AUTOIMMUNE DISEASES WORKING PARTY (ADWP) OF THE EUROPEAN SOCIETY FOR BLOOD AND MARROW TRANSPLANTATION (EBMT)

Background:

Takayasu arteritis (TAK) is a chronic granulomatous large-vessel vasculitis, characterized by arterial thickening and fibrosis leading to stenosis and vascular occlusions. More than 10-20% of patients are refractory to conventional immunosuppressive therapy. Autologous hematopoietic stem cell transplantation (AHSCT) has emerged as a promising treatment option in severely affected and refractory patients with various autoimmune diseases and vasculitis, particularly ANCA-positive vasculitis and Behçet’s disease.

Objectives:

This study,approved by the ADWP, aims to evaluate the use and outcome of AHSCT in adult TAK patients.

Methods:

This is a retrospective survey of patients reported to the EBMT registry between 1998 and 2019, who received AHSCT primarily for TAK. Clinical and laboratory data, including data on diagnosis, previous lines of therapy, transplant regimen, treatment-related mortality, as well as data regarding course of disease and treatment were recorded.

Results:

Data from six adult patients treated with AHSCT between 2003 and 2019 for refractory Takayasu have been identified. Median (ranges) follow-up was 9.9 (1-14) years. Five patients were female (83%), median age was 25 (9-39) years at diagnosis and 28 (22-41) years at HSCT. All patients were pretreated with a median of 6 (4-8) lines of therapy, including systemic steroids (6 patients), methotrexate (5 patients), cyclophosphamide, mycophenolate mofetil or infliximab (4 patients), tocilizumab or etanercept (2 patients), and other biologic or conventional-synthetic DMARDs. Conditioning included cyclophosphamide and rabbit anti-thymocyte globulin in all patients. At six months post-transplantation, remission was obtained in all cases, which persisted at 12 months in 5 cases. Four patients reactivated TAK at a median time of 27 (7-52) months after AHSCT, and 3 resumed disease-modifying therapy. At last follow-up, all patients were alive, 2 patients were in remission (off-therapy), 2 patients improved compared to baseline, and 2 patients were in complete and partial remission, respectively, under immunosuppressive treatment.

Conclusion:

This small retrospective series demonstrates that AHSCT has the potential to provide significant clinical responses in TAK patients who had been unresponsive to previous immunosuppressive therapy, with an acceptable safety profile.

Acknowledgments:

no

Disclosure of Interests:

CHARLOTTE LAURENT: None declared, ZORA MARJANOVIC: None declared, Jörg Henes Grant/research support from: Novartis, Roche-Chugai, Consultant of: Novartis, Roche, Celgene, Pfizer, Abbvie, Sanofi, Boehringer-Ingelheim,, DOMNIQUE FARGE: None declared, MANUELA BADOGLIO: None declared, John SNOWDEN: None declared, olivier fain: None declared, Tobias Alexander: None declared, Maria Carolina Oliveira: None declared, Arsene Mekinian: None declared

AB0161 CLONAL HEMATOPOIESIS IS INCREASED AND NOT RELATED TO AGING IN SYSTEMIC SCLEROSIS

Background:

Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis, microangiopathy and immune dysfunctions including dysregulation of proinflammatory cytokines. Clonal hematopoiesis of indeterminate potential (CHIP) is defined by the acquisition of somatic mutations in hematopoietic stem cells leading to detectable clones in the blood. Recent data have shown a higher risk of cardiovascular disease in patients with CHIP resulting from increased production of proinflammatory cytokines and accelerated atherosclerosis. Eventual links between CHIP and autoimmune diseases are undetermined.

Objectives:

The aim of our study was to evaluate the prevalence of CHIP in SSc patients and its association with clinical phenotype.

Methods:

Forty-one genes frequently mutated in myeloid malignancies were sequenced in peripheral blood mononuclear cells from 90 SSc patients and from 44 healthy donors.

Results:

A total of 15 somatic variants was detected in 13/90 SSc patients (14%) and 4 somatic variants in 4/44 (9%) HD (p=0.58). The prevalence of CHIP was significantly higher in younger SSc patients than in HD: 25% (6/24) vs 4% (1/26) (p=0.045) under 50 years and 17% (7/42) vs 3% (1/38) (p=0.065) under 60 years. The prevalence of CHIP in patients over 70 years was similar in SSc patients and healthy donors

For SSc patients the most common mutations occurred inDNMT3A(7 variants). Other variants involvedATM,SF3B1, SETBP1, TET2,TP53,NF1orCBL. The distribution of gene mutations was overall comparable in SSc patients and in previously described CHIP series (3)

In most SSc patients, we identified a single CHIP mutation. Several mutations were detected in two SSc patients:SETBP1andNF1in one and,TET2andATMin the other Clonal mutations included missense (n=10), nonsense (n=3), frameshift (n=1) and a single splice site mutation. In all HD we detected a single CHIP mutation which occurred inDNMT3A, TP53 and CSF3R

Variant allele frequencies (VAF) of CHIP mutations ranged from 2 to 18.6% and did not differ between genes (DNMT3Aor others). Mean age was the same in patients withDNMT3Amutations or with other mutations. However, C>T transversions, that have been associated with ageing were more frequent inDNMT3Avariants than in other genes, suggesting distinct mechanisms for mutation acquisition or clonal selection No major differences in clinical and laboratory data were observed between SSc patients with or without CHIP. SSc subtypes, disease duration, different organ involvements and the prevalence of ischemic events were not associated with the presence of CHIP, except less frequent pyrosis in patients with CHIP than those without. SSc patients with CHIP had significantly more anti-RNA polymerase III antibodies than those without CHIP (p=0.045) At the time of analysis, 45 SSc patients had received a treatment for SSc which consisted in low-dose steroids, hydroxychloroquine, mycophenolate mofetil, cyclophosphamide or methotrexate. SSc patients with CHIP were significantly more exposed to cyclophosphamide (3/13 vs. 3/77) (p=0.04) (5, 6.5 and 11 gram respectively between 5 years to 8 years before the NGS sequencing analysis), but among these cyclophosphamide-exposed SSc the age was over 65 in 2/3 of them. When considering all immunosuppressive drugs (cyclophosphamide, methotrexate and mycophenolate mofetil) SSc patients with CHIP were not more exposed than those without CHIP (p=0.75) No patient developed any hematologic malignancy and no cytopenia during the median follow-up of 13 months (0-24 months). One SSc patients with CHIP developed a small lung cancer few months after NGS testing.

Conclusion:

Whether CHIP increases the risk to develop SSc or is a consequence of a SSc-derived modified bone marrow micro-environment remains to be explored.

Acknowledgments:

na

Disclosure of Interests:

None declared

FRI0211 VASCULITIS ASSOCIATED WITH MYELODYSPLASTIC SYNDROME AND CHRONIC MYELOMONOCYTIC LEUKEMIA: FRENCH MULTICENTER CASE CONTROL STUDY

Background:

Myelodysplastic syndromes (MDS) and MDS/myeloproliferative neoplasms (MDS/MPN) can be associated with vasculitis.

Objectives:

In this nationwide study by the “French Network of dysimmune disorders associated with hemopathies” (MINHEMON) the objective was to evaluate characteristics, treatment and outcome of vasculitis MDS-MDS/MPN.

Methods:

Retrospective analysis of patients that presented a MDS/MPN associated with vasculitis and compared the overall survival and acute leukemia with MDS without vasculitis.

Results:

Seventy patients with vasculitis and MDS/MPN were included, with a median age of 71.5 [21-90] years and male/female ratio of 2.3. Vasculitis was diagnosed prior to MDS/MPN in 31 patients (44.3%), with a median time of 27 months [1-120] between two diagnosis, and after in 20 patients (6 months [1-59]). In comparison to 183 MDS/MPN without dysimmune features showed no difference in MDS/MPN subtypes distribution nor median IPSS/CPSS scores in patients with and without vasculitis. The vasculitis subtypes was giant-cell arteritis (GCA) in 24 patients (34%). Eleven patients (20%) had Behçet’s-like syndrome and 6 patients (9%) presented with polyarteritis nodosa. Steroids (60 mg/day [0-500] of prednisone equivalent) were used as first-line therapy for MDS/MPN vasculitis in 64/70 patients (91%) and 41 (59%) received combined immunosuppressive therapies during the follow-up. After the follow-up of 33.2 months [1-162], 31 patients (44%) finally experienced sustained remission. At least one relapse during the 33.2 months [1-162] follow-up occurred in 43 patients (61%). Relapse rates were higher in patients treated by DMARDs (odds ratio at 4.86 [95% CI 1.38 - 17.10]), but did not differ from biologics (odds ratio 0.59 [95% CI 0.11-3.20]) and azacytidine (odds ratio 1.44 [95% CI 0.21-9.76]) (steroids considered as reference). Overall survival and progression to acute myeloid leukemia in MDS/MPN vasculitis were not significantly different from MDS/MPN patients without any dysimmune features (p=0.5).

Conclusion:

This first largest study of MDS/MPN vasculitis show no correlation of vasculitis subtypes with various subtypes and severity of MDS/MPN, and no significant impact of vasculitis on overall survival and progression to acute myeloid leukemia. The high relapse rats and steroid dependence raise the question of combined therapies to steroids. Whereas DMARDs use seem to be avoid specific azacytidine therapy could be considered for even low-risk MDS/MPN vasculitis.

Acknowledgments:

minhemon gfm gfev

Disclosure of Interests:

None declared

AB0508 EFFICACY AND SAFETY OF TNF-Α ANTAGONISTS AND TOCILIZUMAB IN TAKAYASU ARTERITIS: MULTICENTER EUROPEAN RETROSPECTIVE STUDY OF 203 PATIENTS

Background:

Takayasu arteritis (TA) is a chronic inflammatory large-vessel vasculitis, predominantly affecting the aorta and its main branches

Objectives:

To assess safety and efficacy of biologics (i.e. TNF-α antagonists and tocilizumab) in patients with Takayasu arteritis (TA).

Methods:

We conducted a retrospective multicenter study in referral centers from Europe and several countries in the world about biological-targeted therapies in Takayasu arteritis during the period from January 2017 to September 2019.

Results:

Retrospective multicenter study of characteristics and outcome of 49 TA patients [80% of females; median age 42 [20-55] years] treated by TNF-α antagonists (80%) or tocilizumab (20%)] and fulfilling ACR and/or Ishikawa criteria. Factors associated with complete response were assessed. Eighty-eight percent of TA patients were inadequately controlled with, or intolerant to, conventional immunosuppressive therapy [median number of 3 (1-5)]. Overall response (i.e. complete and partial) to biological-targeted treatments at 6 and 12 months was of 75% and 83%, respectively. There were a significantly lower C-reactive protein levels at initiation of biological-targeted treatments [22 [10-46] mg/l vs 58 [26-76] mg/l, (p=0.006)] and a trend toward lower immunosuppressants drugs used prior biologics (p=0.054) in responders (i.e. complete and/or partial responders) relative to non-responders to biological-targeted treatments. C-reactive protein levels and daily prednisone dosage significantly decreased after 12 months of biological-targeted treatments [30 vs 6 mg/l, p<0.05 and 15 vs 7.5 mg, p<0.05, at baseline and at 12 months, respectively]. The 3-year relapse free survival was of 90.9% (83.5-99) over biologic treatment period compared to 58.7% (43.3-79.7) (p=0.0025) with DMARDs. No difference was found relative to efficacy between TNF-α antagonists and tocilizumab. After a median follow-up of 24 [2-95] months, 21% of adverse effects occurred, with biological-targeted treatments discontinuation in 6.6% of cases.

Conclusion:

This nationwide study shows high efficacy of biological-targeted treatments in refractory TA patients with an acceptable safety profile.

Acknowledgments:

NO

Disclosure of Interests:

Arsene Mekinian: None declared, Mathieu Vautier: None declared, Matthieu resche-rigon: None declared, Lorenzo Dagna Grant/research support from: Abbvie, BMS, Celgene, Janssen, MSD, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, SG, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Novartis, Pfizer, Roche, SG, and SOBI, Savino Sciascia: None declared, olivier.espitia@chu-nantes.fr olivier.espitia@chu-nantes.fr: None declared, Patrice cacoub: None declared, olivier fain: None declared, david Saadoun: None declared

AB0509 SUSPENSIVE EFFICACY OF TOCILIZUMAB IN TREATMENT-NAÏVE PATIENTS WITH TAKAYASU ARTERITIS: TOCITAKA FRENCH PROSPECTIVE MULTICENTER OPEN-LABELLED TRIAL

Objectives:

To assess long term efficacy of tocilizumab in treatment-naive patients with Takayasu arteritis (TAK).

Methods:

In this multicenter, prospective, open-labelled trial, we aim to evaluate the benefit of adding tocilizumab to steroids in treatment-naïve patients with TAK, on discontinuation of steroids after 6 months of tocilizumab treatment, and to assess relapse-free survival following tocilizumab discontinuation.

Results:

Thirteen patients with TAK were included, with a median age of 32 years [19-45] and 12 (92%) females. Six (54%) patients met the primary end-point. Among 11 (85%) patients which achieved remission at 6 months, 6 (54%) have reached primary endpoint.. Among the 5 remaining patients which continued steroids, 3 had a prednisone-equivalent dosage < 5mg/day. A significant decrease of disease activity was observed after 6 months of tocilizumab therapy: decrease of median NIH scale (3 [3-4] at baseline, versus 1 [0-2] after 6 months; p <0.001), ITAS-2010 score (5 [2-7] versus 3 [0-8]; p = 0.002), and ITAS-A score (7 [4-10] versus 4 [1-15]; p = 0.0001)]. All patients discontinued tocilizumab after 7 infusions, and no other immunosuppressive drugs was introduced, except for 1 patient which received methotrexate. After 9 and 12 months, respectively 7 (54%) and 6 (50%) patients achieved remission with less than 7.5 mg/day of prednisone, and 9 (69%) and 9 (75%) with doses <10 mg/day. During the 12 months follow-up after tocilizumab discontinuation, a relapse occurred among 5 patients (45%) out of 11 in which achieved remission after 6 months of tocilizumab.

No severe AEs were considered related to study treatment and none required tocilizumab interruption or dose reduction. No deaths have occurred during the study period.

Conclusion:

Tocilizumab seems an effective steroid sparing therapy in TAK but its effect appears to be suspensive.

Disclosure of Interests:

Arsene Mekinian: None declared, david Saadoun: None declared, jerome.connault@chu-nantes.fr jerome.connault@chu-nantes.fr: None declared, i-quere@chu-montpellier.fr i-quere@chu-montpellier.fr: None declared, Patrick Jégo: None declared, nicolas.limal@aphp.fr nicolas.limal@aphp.fr: None declared, wxv wxv: None declared, Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Mathieu Vautier: None declared, lea.savey@aphp.fr>; lea.savey@aphp.fr>;: None declared, Patrice cacoub: None declared, olivier fain: None declared