AB1308 MYCOPHENOLATE FOR THE TREATMENT OF EYE INVOLVEMENT IN PATIENTS WITH BEHÇET’S SYNDROME

Background

Experience with mycophenolate in uveitis associated with Behçet’s syndrome (BS) is limited.

Objectives

We aimed to report the efficacy and safety of mycophenolate mofetil (MMF) and mycophenolate sodium (MPA) in the treatment of BS uveitis.

Methods

All patients with panuveitis or posterior uveitis who used mycophenolate for eye involvement between 2016 and 2018 were included. Patient charts were reviewed and data on demographic features, previous immunosuppressives, concomitant therapies, ocular attacks and outcome, and adverse events were extracted. Follow up was ended on October 2021.

Results

We included 12 BS patients (M/W: 8/4, mean age: 35±7 years) treated with mycophenolate during a mean follow-up of 42±19 months (Table 1). All but 3 patients had bilateral eye involvement. IFX and INF-α had been discontinued due to adverse events in all patients, AZA in 10/12, and Cy-A in 7/10.

Table 1.

Demographic, treatment and outcome of the 12 patients

Age /genderPrevious therapiesRemission induction or Maintenance therapyConcomitant biologicTime to ocular attack (months)Treatment after ocular attackAt the end of the follow-upMMF duration (months)25/MAZA,Cy-ARemission inductionNone2ADA was addedADA and MPAa were switched to INF due to further ocular attacks3842/WAZA,Cy-A, INF, IFXRemission inductionIFXN/AN/AStill on IFX and MMF7237/MAZA,Cy-A, INF, IFX, ADARemission inductionADAN/AN/AStill on ADA and MMF2732/MAZARemission inductionNone12IFX was addedStill on IFX and MMF5233/WAZA, Cy-A, INF, ADA, IFXRemission inductionNoneN/AN/AMPAb was switched to certolizumab and MTX524/MAZARemission inductionIFXN/AN/AStill on MMF and IFX was stopped due to remission6337/MAZA, Cy-ARemission inductionNone6IFX was addedIFX and MMF were switched to INF due to further ocular attacks4136/WAZA,Cy-A, INFMaintenanceNone2ADA was addedStill on ADA and MMF5036/MAZA,Cy-A, INF, IFXMaintenanceIFXN/AN/AStill on IFX and MMF was stopped due to remission1749/WAZA,Cy-A, INFMaintenanceNoneN/AN/AStill on MMF3937/MAZA, INFMaintenanceNone31Cy-A was addedStill on MMF and Cy-A38 d31/MAZA, Cy-A, INFMaintenanceNone5IFX was addedOff treatment for 2 years38

a MMF was switched to MPA due to numbness in hands and feet, and MPA was stopped due to arthralgia.

b MMF was switched to MPA due to diarrhea

Seven patients were prescribed mycophenolate for remission induction. One of these patients had had his first uveitis attack while on AZA treatment due to gastrointestinal involvement. The remaining 6 patients were using other immunosuppressives and experienced relapses that led to mycophenolate use. MMF was added to a biologic agent in 2 patients (IFX and ADA) and was initiated in combination with IFX in 1 patient. These 3 patients did not experience further ocular attacks and IFX was stopped due to remission in 1 patient. In the fourth patient, MMF was switched to MPA due to numbness in hands and feet and MPA was stopped due to arthralgia. This patient did not experience ocular attacks during 5 months of MPA therapy. The remaining 3 patients had further uveitis attacks without decrease in visual acuity 2, 6, and 12 months after MMF initiation, and IFX was added in 2 patients, and ADA in 1 patient. Two of these patients were switched to INF-α due to uveitis relapses. MMF was switched to MPA for diarrhea in 1 patient.

Five patients had received MMF for maintenance. One of these was using IFX when MMF was started and these 2 agents were used together. This patient discontinued MMF due to remission 17 months after MMF initiation and is still on IFX monotherapy. The second patient is still on MMF for 39 months without further ocular attacks. ADA, IFX and Cy-A were added in the remaining 3 patients due to ocular attacks 2, 5 and 31 months after MMF initiation. One of these 3 patients stopped IFX and MMF due to remission and is off treatment for 2 years.

Conclusion

Mycophenolate may be an alternative treatment modality in addition to biologics for patients with eye involvement who are intolerant to conventional therapies. Further data is needed to show whether it would be effective when used alone.

Disclosure of Interests

Didar Ucar: None declared, Yilmaz Ozyazgan: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme, Emir Cerme: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Melike Melikoglu: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

AB1305 A SYSTEMATIC REVIEW OF AA AMYLOIDOSIS AMONG PATIENTS WITH BEHÇET’S SYNDROME

Background

Data on patients with Behçet’s syndrome (BS) complicated with AA amyloidosis is limited to case reports or case series with a small number of patients.

Objectives

In this study, we aimed to perform a systematic review (SR) of published reports on BS patients with AA amyloidosis.

Methods

PubMed and EMBASE were searched with the keywords “Behcet* AND amyloidosis”, without date and language restriction, until May 2020. Two independent reviewers (SNE, GK) performed title/abstract and full text screening and data extraction. A third reviewer (GH) made the final decision in case of disagreement between the two reviewers. Studies that reported patients who were reported by authors as having BS and AA amyloidosis were included. The risk of bias assessment was done using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.

Results

The systematic literature search yielded 760 articles of which 703 were excluded after title and abstract review. After full-text review, we further excluded 15 duplicate articles and 1 article was added after handsearching the reference lists of the full texts. Finally, we included 43 articles reporting 96 cases. Among these articles, 38 were case reports and 5 were case series reporting between 6 and 14 patients. All patients but 8 were reported from Mediterranean countries. The quality of all articles according to GRADE was very low due to the lack of a control group.

The main features of the patients were male predominance (81/96, 84%), a high frequency of major organ involvement (62/80, 77.5%) especially vascular involvement (60%), a low frequency of comorbidities predisposing to AA amyloidosis (11/96, 11.5%), and a very low frequency of gastrointestinal involvement (3/72, 4%). All but 8 patients were diagnosed with BS and AA amyloidosis simultaneously. The most common presentation was nephrotic syndrome (60/81, 74%). Presenting symptoms other than proteinuria were diarrhea (n=2), acute renal failure (n=2), upper gastrointestinal bleeding (n=1), end stage renal disease (ESRD) (n=1), cardiac symptoms due to cor pulmonale (n=1), and hypertension (n=1). Renal biopsy (72%) and rectal biopsy (17%) were the most commonly used procedures to diagnose AA amyloidosis.

After diagnosing AA amyloidosis, colchicine was initiated in 58 patients, cyclophosphamide in 16, and biologics in 3 (1 anakinra and 2 tocilizumab). In the 67 patients with available data on follow-up, 43% of the patients were followed-up for ≤1 year and median follow-up duration was 20 months (IQR: 4-48). Among the 64 patients with available data, 30 (47%) had developed ESRD. Among the 72 patients with available data on survival status, 30 patients (42%) had died. Ten patients (33%) had died within 6 months, 15 had died after a median follow-up of 48 months (IQR: 24-150), and follow-up duration was not available in the remaining 5 patients including 3 patients whose diagnoses were made by autopsy. Reasons for death were infection (n=7), ESRD (n=6), intractable diarrhea (n=3), pulmonary embolism (n=1), cor pulmonale (n=1), hemorrhage due to pulmonary artery aneurysm (n=1), liver cirrhosis (n=1), gastric cancer (n=1), subarachnoid hemorrhage (n=1), and not reported (n=8).

Conclusion

Male gender and major organ involvement, especially vascular involvement, appear to be risk factors for the development of AA amyloidosis in BS patients. While BS patients complicated with AA amyloidosis have been reported rarely, it is a fatal complication of BS. One third of the patients had died within 6 months after AA amyloidosis diagnosis.

Disclosure of Interests

Güzin Karatemiz: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme., Mert Gurcan: None declared, Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Sebahattin Yurdakul: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Izzet Fresko: None declared, Melike Melikoglu: None declared, Emire Seyahi Speakers bureau: Emire Seyahi has received honorariums for presentations from Novartis, Pfizer, AbbVie, and Gliead., Serdal Ugurlu: None declared, Huri Ozdogan: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

POS0816 DRUG SURVIVAL OF INFLIXIMAB IN BEHÇET’S SYNDROME PATIENTS WITH DIFFERENT TYPES OF INVOLVEMENT

Background

Infliximab (IFX) is an effective therapeutic option in the management of severe and refractory manifestations of Behçet’s syndrome (BS).

Objectives

We aimed to evaluate long term drug survival of IFX in a large cohort of BS patients.

Methods

We reviewed the charts of BS patients who received IFX between 2004 and June 2021 and noted demographic features, reasons for IFX use, IFX duration, and reasons for discontinuation.

Results

371 patients (290 men, mean age at IFX initiation: 35.5 ± 10 years) received IFX for uveitis (n=164), vascular involvement (n=114), central nervous system (CNS) involvement (n=55), arthritis (n=19), gastrointestinal (GI) involvement (n=15), mucocutaneous involvement (n=10), venous ulcers (n=13), and secondary amyloidosis (n=1). Twenty patients had more than one type of involvement requiring IFX.

During a median follow-up of 30 months (IQR: 13-52), 175 (47%) patients were still receiving IFX for a median period of 40 months (IQR: 22-66) while 196 (53%) patients had discontinued IFX after a median follow-up of 19 months (IQR: 8-34).

IFX retention rate was 50% for mucocutaneous involvement, 43% for uveitis, 49% for vascular involvement, 58% for CNS involvement, 37% for arthritis, 53% for GI involvement, and 31% for venous ulcer (Table 1).

Table 1.

Drug survival of infliximab and reasons for infliximab discontinuation

Mucocutaneous involvement (n=10)Uveitis (n=164)Vascular (n=114)CNS (n=55)Arthritis (n=19)GIS (n=15)Venous ulcer (n=13)Male (n, %)3 (30)127 (77)89 (78)49 (89)14 (74)9 (60)12 (92)Age at infliximab initiation (mean ± SD years)35.8 ± 9.334 ± 9.936 ± 9.136.2 ± 10.439.6 ± 10.743 ± 14.137.4 ± 8.2Number of patients who used concomitant immunosuppressives (n, %)5 (50)108 (66)86 (75)38 (69)5 (26)11 (73)7 (54)Duration of infliximab use (mean ± SD months)33 ± 3845 ± 3828 ± 2337 ± 2837 ± 3526 ± 2625 ± 25Number of patients who discontinued infliximab (n, %)5 (50)93 (57)58 (51)23 (42)12 (63)7 (47)9 (69)Due to remission-30212121Due to primary inefficacy157---5Due to secondary inefficacy212545--Due to adverse event1231211541Due to noncompliance11113--2Due to other reasons-1212311-

Reasons for discontinuation were adverse events in 56 (15%), remission in 54 (15%) patients, inefficacy in 45 (12%) (secondary inefficacy in 26 (7%), primary inefficacy in 19 (5%)), and lack of patient compliance in 18 (5%). Other reasons were preparation for surgical operation (n=4), pregnancy (n=4), lack of health insurance (n=4), preferring subcutaneous administration during the pandemic (n=3), due to prison sentence (n=3), willing to get pregnant (n=1), rejecting the treatment (n=1), and death (n=3).

Adverse events (n=56) leading to the cessation of IFX were infusion reactions (n=22), infections (n=7), tuberculosis (n=6), malignancy (n=6), palmoplantar psoriasis (n=5), hepatotoxicity (n=4), lichen planus (n=1), drug induced lupus (n=1), auricular chondritis (n=1), macrophage activation syndrome (n=1), splenic infarction (n=1) and a decrease in left ventricular ejection fraction (n=1).

At the end of the follow-up, 2 patients had died due to lung adenocarcinoma, 1 patient had died due to pneumosepsis, 1 due to severe parenchymal neurologic involvement and 1 with pulmonary artery involvement due to massive hemorrhage during IFX treatment. Additionally, 7 patients had died 9, 10 months, 3, 3, 4, 7 and 9 years after IFX discontinuation. The causes of death were severe nervous system involvement in 2 patients, right heart failure due to pulmonary hypertension, laryngeal adenocarcinoma, lung adenocarcinoma, sepsis and gastrointestinal bleeding in 1 patient each.

Conclusion

IFX seems to be effective for the treatment of organ and life-threatening manifestations in the majority of the patients. However, drug retention rate was not optimal, mainly due to adverse events, inefficacy and patient non-compliance.

Disclosure of Interests

Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme, Beyza Tukek: None declared, Sitki Safa Taflan: None declared, Yilmaz Ozyazgan: None declared, Didar Ucar: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Emire Seyahi Speakers bureau: Emire Seyahi has received honorariums for presentations from Novartis, Pfizer, AbbVie, and Gliead, Melike Melikoglu: None declared, Ugur Uygunoglu Speakers bureau: Ugur Uygunoglu has received speaker fees from F Hoffmann La-Roche, F Hoffmann La-Roche, Bayer, Merck-Serono, Novartis, Teva, and Biogen Idec/Gen Pharma of Turkey, Consultant of: Ugur Uygunoglu has received advisory board honorariums from F Hoffmann La-Roche, F Hoffmann La-Roche, Bayer, Merck-Serono, Novartis, Teva, and Biogen Idec/Gen Pharma of Turkey, Aksel Siva Speakers bureau: Aksel Siva received honorariums from Teva for speaking engagements., Consultant of: Aksel Siva received honorariums from Bayer-Schering AG, Biogen/Gen Ilac of Turkey, Genzyme, Merck-Serono, and Roche for consulting, fees from Novartis as a consultant and advisory committee member,., Grant/research support from: Aksel Siva received travel and registration reimbursements from Genzyme., Zekayi Kutlubay: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

POS0814 OUTCOME OF VASCULAR INVOLVEMENT OF BEHÇET’S SYNDROME TREATED WITH INFLIXIMAB: A RETROSPECTIVE COHORT STUDY

Background

Vascular involvement is the most common cause of mortality and an important cause of disability in patients with Behçet’s syndrome (BS). Cyclophosphamide has been the treatment choice for severe vascular involvement, but high frequency of adverse events such as infertility and infections cause concern. TNF inhibitors can be an alternative for BS patients with vascular involvement.

Objectives

To survey the efficacy and safety of infliximab (IFX) in BS patients with arterial and venous vascular involvement.

Methods

We reviewed the charts of BS patients who used IFX for vascular involvement. We extracted data on demographic and clinical features, type of vascular involvement, laboratory tests, imaging modalities, concomitant immunosuppressives, duration of IFX use, and outcome. The primary endpoint was remission, defined as the presence of all of the following 3 parameters: 1) lack of new clinical symptoms/findings associated with the vascular lesion 2) normalization of CRP level defined as <10 mg/dl) 3) lack of worsening of the primary vascular lesion or a new lesion vascular at another site on imaging. Remission was assessed at month 6 and month 12. Secondary endpoints were relapse, overall disease activity assessed with BDCAF at baseline and at the final visit, development of new organ involvement other than vascular involvement during IFX treatment, severe adverse events leading to discontinuation of IFX therapy, hospitalization or death, and death.

Results

Among the 371 patients who used IFX between 2004 and June 2021, 127 patients (102 men, 25 women, mean age 40 ± 8.7 years) had used it for vascular involvement. The types of vascular involvement that required IFX were venous thrombosis in 61 patients (48%), pulmonary artery involvement in 37 (29%), non-pulmonary artery involvement in 16 (13%), and venous ulcer in 13 (10%). Remission rate was 72% (92/127) at month 6 and 61% (71/117) at month 12. 17/99 (17%) patients experienced 22 relapses during a mean follow-up of 28.4±21 months of IFX therapy. Among the 22 relapses, 12 were the progression of the pre-existing vascular lesion and 10 were new vascular lesions. Overall disease activity improved with a decrease in mean BDCAF score from 1.76 ± 1.27 to 0.6 ± 0.8 at the final visit (p<0.001). Remission and relapse rates according to type of vascular involvement and causes of IFX discontinuation are presented in the Table 1. Adverse events leading to IFX discontinuation were infusion reactions in 5, tuberculosis, disseminated zona, lung adenocarcinoma, fibromyxoid sarcoma, heart failure, SLE, palmoplantar pustulosis, auricular chondritis, and aortic stent graft infection in 1 patient each.

Table 1.

The frequency of concomitant immunosuppressive use, duration of infliximab use and outcomes of BS patients with vascular involvement treated with IFX

Venous thrombosis (n=61)Pulmonary artery involvement (n=37)Non-pulmonary arterial involvement (n=16)Venous ulcers (n=13)Overall (n=127)Number of patients who used concomitant immunosuppressives48 (79)24 (65)14 (87)7 (54)93 (73)Duration of IFX use (mean ± SD months)24 ± 19.725 ± 19.335 ± 29.626 ± 2425 ± 21Remission rate at month 650 (82)31 (84)10 (63)1 (8)92 (72)Remission rate at month 12a40 (70)21 (64)8 (53)2 (17)71 (60)Relapse rate4 (7)4 (11)9 (60)017 (13)Number of patients who discontinued IFX31 (51)23 (62)5 (31)9 (69)68 (54)Due to remission1560122Due to inefficacy313411Due to relapse10102Due to adverse event741113Due to noncompliance340310Due to new organ development10001Due to other reasonsb18009Death22004

a Since 10 patients did not reach the 12th month yet, the percentages were calculated on 117 patients.

b Other reasons were preparation for surgical operation (n=2), not wanting to come to the infusion frequently during the pandemic (n=2), pregnancy (n=1), willing to get pregnant (n=1), lack of health insurance (n=1), due to prison sentence (n=1), and death (n=1).

Conclusion

Infliximab may be beneficial in BS patients with vascular involvement, even in those who are refractory to immunosuppressives and corticosteroids.

Disclosure of Interests

Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Gulen Hatemi has received grant/research support from Celgene, Beyza Tukek: None declared, Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme., Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Sitki Safa Taflan: None declared, Melike Melikoglu: None declared, Serdal Ugurlu: None declared, Izzet Fresko: None declared, Zekayi Kutlubay: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene.

POS0819 EMERGENCE OF DE NOVO MANIFESTATIONS DURING INFLIXIMAB TREATMENT IN BEHÇET SYNDROME

Background:

Infliximab (IFX) is increasingly used in the management of severe, relapsing or refractory manifestations of Behçet Syndrome (BS). Emergence of de novo manifestations have been reported during IFX treatment, despite efficacy for the initial manifestation that required IFX use1.

Objectives:

We aimed to survey a sizeable cohort of BS patients treated with IFX for the development of de novo manifestations during treatment.

Methods:

A chart review was conducted to identify all BS patients who were given IFX in our Behçet Disease Research Center between 2004 and 2020. Demographic data, indications for IFX initiation, concomitant drugs, prior treatments, and outcomes were recorded. De novo manifestations were defined as new BS manifestations that had not occurred before IFX treatment.

Results:

A total of 252 patients used IFX with the main indications being uveitis in 122, vascular involvement in 82, parenchymal central nervous system involvement in 32, gastrointestinal involvement in 11, arthritis in 10, mucocutaneous involvement in 4, and secondary amyloidosis in 1. Of these patients, 17 (6%) had developed a total of 21 de-novo manifestations during a mean follow-up of 38.4 ± 92 (SD) months (Table 1). Vascular involvement was the main indication for IFX in the majority (n=12; 71%) of these 17 patients followed by eye involvement (n=3; 18%), central nervous system involvement (n=1), and joint involvement (n=1). Concomitant medications were prednisolone in 14 patients, azathioprine in 6 patients, mycophenolate mofetil, cyclosporine-A and methotrexate in 1 patient each. Thirteen patients (76%) were in remission for the main indication when de-novo manifestations emerged. In 10 patients IFX treatment was intensified either by increasing the dose to 10 mg/kg (2 patients) or by shortening the infusion intervals to 4 weeks (2 patients) along with the addition of corticosteroids or immunosuppressives. In the remaining 7 patients IFX was switched to another agent (cyclophosphamide in 5, adalimumab in 1 and anakinra in 1). At the time of this survey 8/17 patients were still on IFX for a mean follow-up of 32.5 ± 24.6 (SD) months, with concomitant low dose prednisolone in 5, azathioprine in 3 and mycophenolate mofetil in 3. In addition to the 7 patients who discontinued IFX at the time of de-novo manifestations, 2 more patients had discontinued IFX due to allergic reactions.

Conclusion:

De novo manifestations developed during IFX treatment in 6% of BS patients, despite efficacy for the initial manifestation. Appearance of de novo manifestations mostly in patients with vascular involvement is noteworthy. Intensification of IFX treatment was efficacious in managing de novo manifestations in more than half of these patients.

References:

[1]Hamuryudan V et al. Semin Arthritis Rheum. 2015;45(3):369-73.

Table 1.

Distribution of de novo manifestations that have emerged in 17 patients

De-novo manifestations21Pulmonary artery aneurysm1Pulmonary artery thrombosis2Coronary artery involvement3Superficial thrombophlebitis5Arthritis5Erythema nodosum3Gastrointestinal involvement1Central nervous system involvement1

Disclosure of Interests:

None declared

POS0814 DRUG RETENTION RATE, REASONS FOR DISCONTINUATION AND OUTCOME OF INFLIXIMAB USE IN BEHÇET SYNDROME

Background:

Infliximab (IFX) plays a key role in the management of severe and refractory manifestations of Behçet syndrome (BS). However we had previously shown that its sustained use may be limited due to adverse events and lack of patient compliance (1).

Objectives:

To assess the retention rate of IFX, adverse events, causes of discontinuation and outcome after cessation of IFX in a larger group of BS patients who were followed in a tertiary center.

Methods:

The charts of BS patients who were prescribed IFX between 2004 and 2020 were reviewed to determine demographic features, reasons for IFX use, previous and concomitant drugs, IFX duration, reasons for cessation of IFX and time to flare following cessation of IFX. Follow-up was censored on March 2020.

Results:

A total of 252 patients (195 men, mean age 40±10 years) received IFX for uveitis (n=122), vascular involvement (n=82), parenchymal neurologic involvement (n=32), gastrointestinal involvement (n=11), arthritis (n=10), mucocutaneous involvement (n=4), and secondary amyloidosis (n=1). Ten patients had more than 1 involvement requiring IFX.

During a median follow-up of 52 (IQR: 30-88) months, 122 (48%) patients were still receiving IFX for a median period of 33 (IQR: 15-56) months while 130 (52%) patients had discontinued IFX after a median follow-up of 17 (IQR: 7-31) months. Reasons for discontinuation were remission in 25 (19%) patients, adverse events in 39 (30%), lack of efficacy in 23 (18%) (4 primary and 19 secondary), lack of patient compliance in 36 (28%), pregnancy in 4, and preparation for surgery in 3 patients.

Adverse events (n=39) that required the cessation of IFX were infusion reaction (n=17), infection (n=7), hepatotoxicity (n=4), malignancy (n=4), palmoplantar psoriasis (n=3), lichen planus (n=1), drug induced lupus (n=1), splenic infarction (n=1), and a decrease in left ventricular ejection fraction (n=1).

Among the 25 patients who discontinued IFX due to remission, 5 (20%) had a relapse after 4, 21, 26, 29, 38 and 46 months. The remaining patients did not experience a relapse during a median follow-up of 35 (IQR: 24-68) months.

At the end of the follow-up, 2 patients had died due to lung adenocarcinoma during IFX treatment and 3 patients had died 1 year, 3 and 8 years after IFX discontinuation. The causes of death were with right heart failure due to pulmonary hypertension in 1, and severe nervous system involvement in 2 of the patients.

Conclusion:

Despite its successful use for the management of potentially organ and life-threatening manifestations in more than half of our patients with BS, long term maintenance was not possible in 42%, mainly due to adverse events, lack of patient compliance and inefficacy.

Reference:

[1]Esatoglu SN, Tukek B, Taflan SS, et al. SAT0258 Drug Retention Rate and Prognosis After Discontinuation of Infliximab in Patients with Behçet Syndrome. Annals of the Rheumatic Diseases 2020;79: 1071-1072.

Reasons for infliximab treatmentNo of patientsNo (%) of patients who were still receiving infliximabNumber (%) of patients who discontinued infliximabReasons for discontinuationDuration of infliximab use(median (IQR) months)Eye involvement12259 (48)63 (52)Remission (n=17)Inefficacy (n=10)Lack of patient compliance (n=19)Adverse event (n=12)Others (n)=5)28 (12.5-52)Vascular involvement8240 (49)42 (51)Remission (n=10)Inefficacy (n=7)Lack of patient compliance (n=12)Adverse event (n=12)Others (n=4)18.5 (9-33.5)Parenchymal neurologic involvement3221 (66)11 (34)Adverse event (n=8)Inefficacy (n=2)Lack of patient compliance (n=1)25 (14.5-50)Gastrointestinal involvement114 (36)7 (64)Remission (n=1)Inefficacy (n=1)Adverse event (n=2)Lack of patient compliance (n=4)7 (2-17)Joint involvement102 (20)8 (80)Inefficacy (n=1)Adverse event (n=5)Lack of patient compliance (n=2)20 (4-35)Mucocutaneous involvement431Inefficacy (n=1)6, 10, 12, 104 monthsAA amyloidosis101Inefficacy (n=1)6 years

Disclosure of Interests:

None declared

POS0820 INFLIXIMAB FOR VASCULAR INVOLVEMENT IN BEHÇET SYNDROME

Background:

Vascular involvement is an important cause of morbidity and mortality in patients with Behçet syndrome (BS). TNF inhibitors have been reported to be effective for almost all serious manifestations of BS but data on vascular involvement is still limited.

Objectives:

To survey the efficacy and safety of infliximab (IFX) in BS patients with vascular involvement followed in a dedicated tertiary center.

Methods:

We reviewed the charts of all BS patients who used IFX and identified those who used this drug for vascular involvement. A standard form was used for extracting data on demographic and clinical features, type of vascular involvement, concomitant immunosuppressives, duration of IFX use, relapses, adverse events and outcome.

Results:

83 patients (67 men, 16 women, mean age 39.5 ± 8.4 SD years) had used IFX for vascular involvement. The number of patients with each type of vascular involvement as the main indication for IFX, and previous treatment modalities right before IFX are presented in the Table 1. 33 patients had more than 1 type of vascular lesion. Additional organ manifestations were eye involvement in 32, central nervous system involvement in 4 and gastrointestinal involvement in 3 patients. All but one patient used IFX at a dose of 5 mg/kg every 6-8 weeks. All patients used concomitant prednisolone and 51 received pulse methylprednisolone during induction. Other concomitant medications were azathioprine in 21 and mycophenolate mofetil in 4 patients. Outcome of IFX treatment at the end of a mean follow-up of 25.9 months (range 1-103) is tabulated according to arterial and venous involvement (Table 1). Overall, 57/83 (68%) patients obtained remission with no further relapses and IFX could be stopped in 12 (14%) of them. IFX was discontinued due to adverse events in 15 patients. These were allergic reactions in 8, tuberculosis, disseminated zona, lung adenocarcinoma, fibromyxoid sarcoma, heart failure, systemic lupus erythematosus, and palmoplantar pustulosis in 1 patient each. Three patients had died. Causes of death were lung adenocarcinoma in one patient and pulmonary hypertension related right heart failure due to pulmonary artery thrombosis in 2 patients.

Conclusion:

Infliximab seems to be beneficial in Behçet syndrome patients with vascular involvement, even in those who are refractory to immunosuppressives and corticosteroids. No further relapses occurred in 68% of the patients, and adverse events leading to discontinuation were observed in 18%.

Arterial Involvement (n=36)Venous Involvement (n=47)Main reason for infliximab usePulmonary artery aneurysm and/or thrombosis, n=29Peripheral artery aneurysm, n=4Aortic aneurysm, n=3Vena cava superior and/or inferior thrombosis, n=5Lower extremity DVT, n=24Budd-Chiari syndrome, n=4Intracardiac thrombosis, n=2Dural sinus thrombosis, n=7Leg ulcer, n=5Previous treatmentFirst line infliximab413Corticosteroids3438Cyclophosphamide (CYC)25 (15/25 refractory to CYC; 10/25 for maintenance after CYC)11 (8/11 refractory to CYC; 3/11 for maintenance after CYC)Interferon-alpha-13Azathioprine2117Mycophenolate Mofetil12Cyclosporine A-2None due to non-compliance21OutcomeRemission, still on infliximab1623Discontinued due to remission48Discontinued due to adverse events59Discontinued due to relapse53Discontinued due to non-compliance53Died2 (1 had previously discontinued due to relapse)1

Disclosure of Interests:

None declared

POS1351 CAUSES OF HOSPITALIZATION IN BEHÇET SYNDROME

Background:

The causes of hospitalization may provide important information on the course of diseases and treatment-related adverse effects.

Objectives:

We aimed to determine the causes and outcome of hospitalizations among patients with Behçet Syndrome (BS) in a dedicated center.

Methods:

We surveyed hospitalization records in our clinic between January 2002 and December 2019 and identified those with a diagnosis of BS. The records of these patients were reviewed for demographic and clinical features, causes of hospitalization and outcome. We divided hospitalization causes into 2 as being BS related (organ involvement or deterioration) and non-BS related (treatment complication or others).

Results:

Three-hundred and thirty BS patients (75% men, mean age 37.7 ±11.4 SD years) were hospitalized for a total of 456 times during 18 years. The mean disease duration was 10.8± 8.8 SD years. Two-hundred and ninety-one (64%) patients were using immunosuppressives (IS) with or without corticosteroids (CSs) and 72 (16%) of them were under biologic treatment at the time of hospitalization. The mean duration of hospitalization was 12.7±10.7 SD days. The reasons for hospitalization were directly related to BS in 259 patients (57%) and non-related to BS in 191 (42%). Six patients were hospitalized for both BS and non-BS related reasons at the same time. The most common reasons were vascular involvement (n=169, 64%) for BS related reasons and infections (n=64, 32%) for non-BS related reasons (Table 1). Patients hospitalized for BS related causes were younger (35.2±10.6 vs 41.1±11.7, p<0.001), had short mean disease duration (8.5±7.5 vs. 13.6±9.4 years, p<0.001), stayed shorter in the hospital (11.6±8.6 vs 14.0±12.9 days p=0.03) and had less frequent IS±CSs use (59% vs 70%, p=0.02) compared to those with non-BS related hospitalizations. There were no differences between the groups regarding gender distribution (203 M/62 F vs. 143 M/54 F) and use of biologic agents (15% vs 17%). Three patients died during hospitalization. The reasons were malignancy, infection and right heart failure due to pulmonary artery thrombosis and pulmonary hypertension, respectively.

Conclusion:

Vascular involvement is the leading cause of hospitalization among BS patients, followed by infections. The predominance of men among hospitalized patients underlines the relatively severe course of BS in men. The retrospective design and inclusion of patients who were hospitalized only in the rheumatology unit are limitations of this study.

Table 1.

Distributions of BS related and non-BS related reasons of hospitalizations

BS patients hospitalized with BS related reasons(n of pts=195, n of hospitalizations=265)*BS patients hospitalized with non-BS related reasons(n of pts=170, n of hospitalizations=197)*Causes of hospitalizations (per hospitalization)Vascular inv. (n=169, 64 %)Pulmonary artery inv. (n=64, 24 %)Deep vein thrombosis (n=39, 15 %)Budd-Chiari synd. (n=24, 9%)Vena cava inf. thrombosis (n=19, 7 %)Peripheral artery inv. (n=15, 6 %)Vena cava sup. thrombosis (n=14, 5 %)Aorta inv. (n=14, 5%)Coronary artery inv. (n=4, 2 %)Infection (n=64, 32%)Pneumonia (n=17, 8%)Tuberculosis (n=8, 4%)Urinary tract inf (n=7, 4%)Gastroenteritis (n=4, 2%)Osteomyelitis (n=3, 2%)Septic arthritis (n=3, 2%)Aspergillosis (n=2, 1%)Nocardia (n=1, 1%)Salmonella (n=1, 1%)Others (n=18, 9%)Neurologic inv. (n=50, 19 %)Parenchymal inv. (n=37, 14%)Dural sinus thrombosis (n=13, 5%)Drug side effects other than infections (n=29, 15 %)Interferon (n=10, 5%)Azathioprine (n=7, 4%)Cyclosporine (n=5, 3%)Steroid (n=3, 2%)TNF antagonists (n=3, 2%)IVIG (n=1, 1%)GI inv. (n=18, 7%)Additional rheumatologic diseases (n=17, 9%)Joint inv. (n=12, 5%)Renal disease (n=16, 8 %)Mucocutaneous inv. (n=10, 4%)Cardiovascular dis. (n=12, 6%)Eye inv. (n=8, 3%)Avascular necrosis (n=4, 2%)Others (n=8, 3%)Malignancy (n=11, 6%)Others (n=40, 20%)

*Some patients were hospitalized more than one times and for both BS related and non-BS related reasons at different time and had more than one type of BS related and/or non-BS related reasons.

Disclosure of Interests:

None declared

SAT0258 DRUG RETENTION RATE AND PROGNOSIS AFTER DISCONTINUATION OF INFLIXIMAB IN PATIENTS WITH BEHÇET SYNDROME

Background:

Infliximab (IFX) has become an important treatment option for all manifestations of Behçet syndrome (BS). Adverse events, loss of efficacy, lack of patient compliance and cost may limit its sustained use in patients with BS.

Objectives:

We aimed to evaluate the drug retention rates, causes of discontinuation and outcome after cessation of IFX.

Methods:

We reviewed the charts of 850 patients with BS who were registered in our clinic between 2009 and 2013 and identified those who had used IFX. The charts of these patients were surveyed for demographic features, the reasons for IFX use, previous and concomitant drugs, IFX duration, reasons for discontinuation and time to flare after discontinuation of IFX. We defined flare as disease activity in the organ involvement that necessitated IFX use. New major organ involvement that developed during or after discontinuation of IFX were also be noted.

Results:

A total of 50/850 patients were treated with IFX (40 men, mean age 40±9.5 years), for uveitis (n=29), vascular involvement (n=11), parenchymal neurologic involvement (n=8), arthritis (n=1) and venous ulcer (n=1). Of these 50 patients, 22 (43%) are still receiving IFX for a median duration of 40 (IQR: 25-83) months. The remaining 28 (47%) patients had discontinued IFX after a median follow-up of 12 (IQR: 7-30) months. Reasons for discontinuation were remission in 7 patients, adverse events in 10, primary lack of efficacy in 2, and lack of patient compliance in 9 patients. Among the 7 patients who discontinued IFX due to remission, only 1 patient with uveitis had a flare, 11 months after discontinuation, while on azathioprine. The remaining 6 did not experience any flares during a median follow-up of 29.5 (IQR: 4-24) months. Five of these patients used azathioprine and 1 used mycophenolate mofetil for maintenance. Among the 10 patients who discontinued due to adverse events, IFX was switched to adalimumab in 3 patients and none experienced flares under adalimumab. The remaining 7 patients continued to receive azathioprine or mycophenolate mofetil without a biologic. Among these, 1 patient with uveitis 1 with arthritis experienced flares 6 months after discontinuing IFX. Among the 9 patients who discontinued IFX due to lack of patient compliance, 3 patients (2 with uveitis and 1 with arthritis) had flares after 5 months, 1 year and 1.5 years. IFX was re-initiated in all. The remaining 6 patients did not experience any flares after a mean follow up of 5±1.5 years. Two with uveitis and 2 with venous thrombosis used azathioprine for maintenance, while 2 patients did not receive further treatment. New major organ involvement was not observed. New BS manifestations developed in 2 patients under IFX, arthritis in one patient and both epididymitis and erythema nodosum in the other.

Conclusion:

Almost half of our patients with BS remained on IFX during a median follow-up of 5.4 years (IQR:2.4-7). Main reasons for discontinuation were adverse events, remission and lack of patient compliance. Our observations further support the efficiency of IFX in managing patients with BS.

Disclosure of Interests:

Sinem Nihal Esatoglu: None declared, Beyza Tukek: None declared, Sitki Safa Taflan: None declared, Yilmaz Ozyazgan: None declared, Didar Ucar: None declared, Emire Seyahi: None declared, Melike Melikoglu: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Ugur Uygunoglu: None declared, Aksel Siva: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

P1490 Congenital right coronary artery fistula into right atrium diagnosed with help of multimodality imaging

Introduction

Coronary artery fistula (CAF) is an anomaly in which abnormal connections are present between the coronary artery and the cardiac chambers or a major vessel. It is an uncommon anomaly with an estimated incidence of 1 in 50,000 live births and usually occurs in isolation.

We report a case of CAF into right atrium in a patient who admitted to our outpatient department with dyspnea and fatique. With help of transthoracic echocardiography (TTE), transesophageal echocardiography (TOE) and cardiac computerized tomography (CCT) we put the definite diagnosis and decided to close this fistula percutaneously with a PDA occluder.

Case

A 43-year- old male admitted to our outpatient department with complaints of exertional dyspnea and fatique for 5 years. His physical examination revealed a holosystolic murmur on the aortic valve area. His TTE showed enlarged right heart chambers with a high pulmonary artery systolic pressure (50 mmHg) and a suspicious flow from the aortic root into right atrium. Qp/Qs was 2.1. TOE depicted a shunt between aorta and right atrium as well, we couldn’t truly demonstrate the connection though .

In order to define the defect precisely, we performed a cardiac CT. Cardiac CT clearly showed a markedly dilated and mildly tortuous and calcified fistula arising from the osteal part of right coronary artery draining into right atrium. Right coronary artery was thin and there was no stenosis. Cardiac CT helped us to exclude coronary arter disease as well.

As it was suitable to close percutaneously, we decided to close it with a PDA occluder.

Conclusion

CAF is a rare, generally congenital anomaly and may cause right heart chamber dilatation and pulmonary hypertension if the diagnosis is missed. It is important to support and clarify the underlying pathology with help of other cardiovascular imaging modalities like cardiac CT and cardiac magnetic resonance imaging (CMR), if TTE and TOE cannot demonstrate us the exact pathology.In our case our choice of extra method was cardiac CT, as we wanted to exclude accompanying coronary artery disease at the same time. In today’s era, the use of multimodality imaging is increasing with a tremendous rate and it helps clinical cardiologists, cardiovascular imaging specialists and interventional cardiologists all.

Abstract P1490 Figure. 2D,3D TOE and CCT images of CAF

Magnetic Resonance Imaging of Cerebral Small Vessel Disease in Men Living with HIV and HIV-Negative Men Aged 50 and Above

We assessed whether HIV status was associated with white matter hyperintensities (WMH), a neuroimaging correlate of cerebral small vessel disease (CSVD), in men aged ≥50 years. A cross-sectional substudy was nested within a larger cohort study. Virologically suppressed men living with HIV (MLWH) and demographically matched HIV-negative men aged ≥50 underwent magnetic resonance imaging (MRI) at 3 Tesla. Sequences included volumetric three-dimensional (3D) T1-weighted, fluid-attenuated inversion recovery and pseudocontinuous arterial spin labeling. Regional segmentation by automated image processing algorithms was used to extract WMH volume (WMHV) and resting cerebral blood flow (CBF). The association between HIV status and WMHV as a proportion of intracranial volume (ICV; log-transformed) was estimated using a multivariable linear regression model. Thirty-eight MLWH [median age 59 years (interquartile range, IQR 55-64)] and 37 HIV-negative [median 58 years (54-63)] men were analyzed. MLWH had median CD4⁺ count 570 (470-700) cells/μL and a median time since diagnosis of 20 (14-24) years. Framingham 10-year risk of cardiovascular disease was 6.5% in MLWH and 7.4% in controls. Two (5%) MLWH reported a history of stroke or transient ischemic attack and five (13%) reported coronary heart disease compared with none of the controls. The total WMHV in MLWH was 1,696 μL (IQR 1,229-3,268 μL) or 0.10% of ICV compared with 1,627 μL (IQR 1,032-3,077 μL), also 0.10% of ICV in the HIV-negative group (p = .43). In the multivariable model, WMHV/ICV was not associated with HIV status (p = .86). There was an age-dependent decline in cortical CBF [-3.9 mL/100 mL/min per decade of life (95% confidence interval 1.1-6.7 mL)] but no association between CBF and HIV status (p > .2 in all brain regions analyzed). In conclusion, we found no quantitative MRI evidence of an increased burden of CSVD in MLWH aged 50 years and older.

Experimental Tractional Retinal Detachment: An Immunohistochemical Study

Purpose

This study investigated the pathogenesis of tractional retinal detachment associated with proliferative vitreoretinopathy in an experimental model, using immunohistochemical staining.

Methods

To produce tractional retinal detachment in rabbit eyes, homologous cultured fibroblasts obtained from the gluteal muscle fascia were injected intravitreously. Right eyes of 20 rabbits in the study group, and 7 rabbits in the control group were followed for 28 days at weekly intervals with indirect ophthalmoscopy and fundus photographs.

Results

During the follow-up period grade III tractional retinal detachment developed in 11 eyes, grade II in six, and grade 1 in three eyes. The spindle-shaped cells contributed predominantly to the development of epiretinal membrane, and a smaller number of round small and large cells. In 10/17 grade II and III eyes, spindle-shaped cells had vimentin, 7/10 had actin, 5/17 had GFAP, 4/17 had S-100 protein immunoreactivity. Round small and large cells expressed S-100 protein, GFAP and actin in 5/17 eyes. Epiretinal membrane appeared to be formed by spindle-shaped fibroblast-like cells and small and large round glia-like cells. Actin positivity of spindle-shaped and round cells was taken as a marker of contractile elements of the cells and their locomotional features.

Conclusions

These features are believed to be involved in contraction of the membrane and retinal detachment.

Frequent oral ulceration during early disease may predict a severe disease course in males with Behçet's syndrome

OBJECTIVES

The numbers and recurrence rates of mucocutaneous manifestations can be highly variable among patients with Behçet's syndrome (BS) but it is not known whether these differences influence the disease course at the long-term.

METHODS

We evaluated the outcome of 30 patients that made up the placebo arm of a 6 months controlled trial of thalidomide and looked at the relation between the frequencies of mucocutaneous manifestations during the trial and the development of major organ involvement necessitating immunosuppressives during the post-trial period.

RESULTS

Fifteen (50%) patients had received immunosuppresives for major organ involvement during the post-trial period. Patients receiving immunosuppressive treatment were significantly younger at the onset of BS compared to those who did not (24.5±5 vs. 29.7±3.8 SD years; p=0.003). The mean number of oral ulcers recorded throughout the trial was significantly higher among patients using immunosuppressives compared to those who did not (2.09±0.96 vs. 1.43±0.8; p=0.029). This significance disappeared when adjusted for age of onset of BS (p=0.16). ROC curve analysis showed that having 10 or more ulcers during 6 months has a sensitivity of 86.7% and a specificity of 53% for the subsequent necessity of immunosuppressive use. The same association was not true for genital ulcers, follicular lesions and erythema nodosum.

CONCLUSIONS

These findings on a limited number of patients suggest that frequent occurrence of oral ulceration during the initial years of the disease may predict the development of major organ involvement in men with BS.