POS0077 SEX DIFFERENCES IN EFFECTIVENESS OF FIRST-LINE TUMOR NECROSIS FACTOR INHIBITORS IN PSORIATIC ARTHRITIS; RESULTS FROM THIRTEEN COUNTRIES IN THE EuroSpA RESEARCH COLLABORATION NETWORK

Background

Evidence demonstrates sex differences in disease presentation, physical function, treatment response and drug retention in patients with psoriatic arthritis (PsA). Data from observational cohort studies indicate female sex is associated with reduced effectiveness of tumor necrosis factor inhibitors (TNFis)1,2. Although, conflicting results are also reported3,4. We sought to validate prior studies using data from a large multinational cohort based on real-life clinical practice.

Objectives

To investigate sex differences in treatment response and drug retention rates in clinical practice among patients with PsA, treated with their first TNFi.

Methods

Data from biologic-naïve PsA patients initiating a TNFi in the EuroSpA registries were pooled. In the primary analysis, propensity-score weighting was applied to assess the causal effect of sex on low disease activity (LDA) according to DAS28-CRP at 6 months. A generalized linear regression model was used to estimate the causal risk difference (RD) and relative risk (RR) of sex on LDA. Possible covariates influencing the outcome were determined a priori and selected based on availability in the database (<20% missing). The final covariates included were country, age, conventional synthetic disease-modifying antirheumatic drug use at baseline and TNFi start year. In the secondary analysis, drug retention was assessed over 24 months of follow-up by Kaplan-Meier curves and log-rank test.

Results

In total, 7,679 PsA patients with available data on DAS28-CRP at 6 months were assessed for treatment response. Baseline characteristics are shown in the Table 1. In the adjusted analysis, the probability for females to have LDA was 17% (RR, 0.83; 95% confidence interval [CI], 0.81 to 0.85) lower compared to males and the difference in probability for having LDA was 13 percentage points (RD, 0.13; 95% CI, 0.11 to 0.15). The survival analysis included 18,599 PsA patients with available data on retention rates. The TNFi 6/12/24-month retention rates were significantly lower in females (81%/68%/56%) compared to males (89%/80%/69%), see Figure 1.

Table 1.

Baseline characteristics of all biologic-naïve PsA patients treated with their first TNFi and available DAS28-CRP at 6 month, data pooled across all countries

FemaleMaleMean (SD), median [IQR] or percentagesMean (SD), median [IQR] or percentagesAge (years)49.7 (12.5)47.8 (11.9)Disease duration (years)4.0 [1.0, 10.0]4.0 [1.0, 10.0]TNFi start year 1999-200929%29% 2010-201326%27% 2014-201625%24% 2017-202020%20%Concomittant csDMARD75%77%DAS28-CRP4.4 (1.2)4.2 (1.2)DAPSA2832 (16)29 (16)CRP (mg/L)7.0 [3.0, 17.0]8.0 [3.3, 19.0]SJC (0-28)3.0 [1.0, 6.0]3.0 [1.0, 6.0]TJC (0-28)6.0 [2.0, 10.0]4.0 [2.0, 9.0]VAS pain, mm61 (23)55 (23)VAS fatigue, mm62 (26)53 (27)

Data are as observed, mean (SD), median [IQR] or percentage. TNFi, tumor necrosis factor inhibitor; csDMARD, Conventional synthetic disease-modifying antirheumatic drugs; DAS28-CRP, Disease Activity Score 28-joint count C reactive protein; DAPSA28, Disease Activity in PsA 28; CRP, C-reactive protein; SJC, swollen joint count; TJC, tender joint count.

Conclusion

Treatment efficacy and retention rates are lower among female patients with PsA initiating their first TNFi. Females presented with higher 28-tender joint count and higher scores on patient reported outcomes at baseline, reflecting differences in disease expression. Recognizing these sex differences is of relevance for customized patient care and may improve patient education.

References

[1]Højgaard, et al. Rheumatology (Oxford). 2018 Sep 1;57(9):1651-1660.

[2]Vieira-Sousa, et al. J Rheumatol. 2020 May 1;47(5):690-700.

[3]Kristensen, et al. Ann Rheum. Dis. 2008 Mar;67(3):364-9.

[4]Iervolino, et al. J Rheumatol. 2012 Mar;39(3):568-73.

Acknowledgements

Novartis Pharma AG and IQVIA for supporting the EuroSpA collaboration.

Disclosure of Interests

Pasoon Hellamand Grant/research support from: Novartis, Marleen G.H. van de Sande Speakers bureau: UCB, Consultant of: Abbvie, Eli Lily, Novartis, UCB, Grant/research support from: Novartis, Janssen, UCB and Eli Lilly, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Thomas Klausch: None declared, Nina Trokovic: None declared, Tuulikki Sokka-Isler Consultant of: Abbvie, Amgen, BMS, Celgene, DiaGraphIT, Medac, MSD, Novartis, Orionpharma, Pfizer, Roche, Sandoz, and UCB, Maria Jose Santos Speakers bureau: Abbvie, AstraZeneca, Lilly, Novartis and Pfizer, Elsa Vieira-Sousa Speakers bureau: MSD, Celgene, Novartis, Janssen, Abbvie and Pfizer, Consultant of: MSD, Celgene, Novartis, Janssen, Abbvie and Pfizer, Grant/research support from: MSD, Celgene, Novartis, Janssen, Abbvie and Pfizer, Anne Gitte Loft Speakers bureau: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: Novartis, Bente Glintborg Grant/research support from: Pfizer, Abbvie, BMS, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Merck, Celgene, Novartis, Ulf Lindström: None declared, Johan K Wallman Consultant of: AbbVie, Amgen, Celgene, Eli Lilly and Novartis, Brigitte Michelsen Grant/research support from: Novartis, Burkhard Moeller Speakers bureau: MSD, Synergy, Eli Lilly, Bristol-Myers-Squibb, Janssen-Cilag, AbbVie and Pfizer, Raphael Micheroli: None declared, Catalin Codreanu Speakers bureau: AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis and Pfizer, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Ewopharma, Lilly, Novartis and Pfizer, Corina Mogosan Speakers bureau: AbbVie, Ewopharma, Lilly, Novartis and Pfizer, Consultant of: AbbVie, Ewopharma, Lilly, Novartis and Pfizer, Karin Laas Speakers bureau: Amgen, Janssen, Novartis and Abbvie, Ziga Rotar Speakers bureau: Abbvie, Novartis, MSD, Medis, Biogen, Eli Lilly, Pfizer, Sanofi, Lek and Janssen, Consultant of: Abbvie, Novartis, MSD, Medis, Biogen, Eli Lilly, Pfizer, Sanofi, Lek and Janssen, Karen Minde Fagerli: None declared, Matija Tomsic Speakers bureau: Abbvie, Amgen, Biogen, Eli Lilly, Janssen, Medis, MSD, Novartis, Pfizer, Sanofi, Sandoz-Lek, Consultant of: Abbvie, Amgen, Biogen, Eli Lilly, Janssen, Medis, MSD, Novartis, Pfizer, Sanofi, Sandoz-Lek, Isabel Castrejon Speakers bureau: Lilly, BMS, Janssen, MSD and Abbvie, Consultant of: Lilly, BMS, Janssen, MSD and Abbvie, Manuel Pombo-Suarez Consultant of: Abbvie, MSD and Roche, Björn Gudbjornsson Speakers bureau: Amgen and Novartis, Consultant of: Amgen and Novartis, Thorvardur Love: None declared, Karel Pavelka Speakers bureau: Pfizer, MSD, BMS, UCB, Amgen, Egis, Roche and AbbVie, Consultant of: Pfizer, MSD, BMS, UCB, Amgen, Egis, Roche and AbbVie, Jakub Zavada Speakers bureau: Abbvie, Elli-Lilly, Sandoz, Novartis, Egis and UCB, Consultant of: Abbvie, Elli-Lilly, Sandoz, Novartis, Egis and UCB, Gökçe Kenar: None declared, Handan Yarkan-Tuğsal: None declared, Merete Lund Hetland Grant/research support from: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Medac, Pfizer, Roche, Samsung Biopies, Sandoz and Novartis, Irene van der Horst-Bruinsma Speakers bureau: BMS, AbbVie, Pfizer and MSD, Consultant of: Abbvie, UCB, MSD, Novartis and Lilly, Grant/research support from: MSD, Pfizer, AbbVie and UCB

OP0257 RISK OF HAEMATOLOGICAL MALIGNANCY IN PATIENTS WITH PSORIATIC ARTHRITIS, OVERALL AND IN RELATION TO TNF INHIBITORS - A NORDIC COHORT STUDY

Background

Several autoimmune inflammatory diseases, including rheumatoid arthritis (RA), are associated with increased risk of malignant lymphomas. There is also a longstanding concern of lymphoma development with tumour necrosis factor inhibitor (TNFi) treatment, but most studies in RA to date do not indicate an additionally increased risk. Corresponding studies in psoriatic arthritis (PsA), both with respect to the underlying risks, and risks in relation to treatment with TNFi, are limited. Data on myeloid malignancies in PsA are scarce.

Objectives

To estimate the risk of haematological malignancy overall and by lymphoid and myeloid types in TNFi treated versus (vs.) biologics-naïve patients with PsA across the five Nordic countries. Additionally, we investigated the underlying risk of haematological malignancies in PsA as compared to the general population.

Methods

We identified patients with PsA starting a first ever TNFi from the clinical rheumatology registers (CRR) in Sweden (SE), Denmark (DK), Norway (NO), Finland (FI), and Iceland (ICE) from 2006 through 2019 (n=10 621). We identified biologics-naïve patients with PsA from a) the CRR (n=18 705, all countries) and b) the national patient registers (NPR, n=27 286, SE and DK only). To estimate the underlying risk of haematological malignancy in PsA, we randomly sampled general population comparators in SE and DK matched on year of birth, sex, and calendar year at start of follow-up, to the patients with PsA.

Through linkage to the mandatory national cancer registers in all five countries, we collected information on haematological malignancy overall, and categorised into lymphoid or myeloid types. By applying a modified Poisson regression, we estimated pooled incidence rate ratio (IRR) with 95% confidence intervals (CI) for TNFi treated vs. biologics-naïve PsA and for PsA vs. the general population, adjusted for age (18-55, 56-65, 66-70, >70 years), sex, calendar period (2006-2010, 2011-2019) and country, and using robust standard errors.

Results

We observed 40 events of haematological malignancies (during 59 827 person-years) among TNFi treated PsA, resulting in a crude incidence rate (IR) of 67 per 100 000 person-years. The corresponding IR was 91 (63 events) for biologics-naïve PsA from the CRR, and 118 (172 events) for biologics-naïve PsA from NPR. This resulted in a pooled IRR of 0.97 (0.69 to 1.37) for TNFi-treated vs. biologics-naïve PsA patients from the CRR, and 0.84 (0.64 to 1.10) vs. biologics-naïve PsA patients from the NPR. The pooled IRR of haematological malignancies in PsA overall vs. the general population was 1.35 (1.17 to 1.55). Throughout, the estimates were largely similar for lymphoid and myeloid malignancies (Figure 1). The crude IR of haematological malignancies were substantially akin across different TNFi agents.

Figure 1.

Pooled incidence rate ratios (IRRs) (95% CI) of haematological malignancy overall and by lymphoid and myeloid types, in first ever TNFi treated versus biologics-naïve patients with PsA, and versus general population comparators. Legend: Lymphoid malignancies include international classification of diseases (ICD) 10 codes C81-86, C88, C90-91. Myeloid malignancies include ICD10 codes C92-95, D45-D46, D47.1, D47.3-5. Incidence rate ratios adjusted for age (18-55, 56-65, 66-70, >70 years), sex, calendar period (2006-2010, 2011-2019) and country, and using robust standard errors.

Conclusion

In this large five-country cohort study, we did not observe any increased risk of haematological malignancies overall, nor for lymphoid and myeloid types, in patients with PsA treated with TNFi. By contrast, there were signals of a moderately increased underlying risk of haematological malignancies, both of lymphoid and myeloid types, in patients with PsA overall as compared to the general population. The findings are of importance from a patient information perspective.

Acknowledgements

We would like to acknowledge the NordForsk and FOREUM, and especially the patient representatives of the NordForsk collaboration for their valuable contribution to this study.

Disclosure of Interests

René Cordtz: None declared, Johan Askling Consultant of: Abbvie, Astra-Zeneca, BMS, Eli Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB, Grant/research support from: Abbvie, Astra-Zeneca, BMS, Eli Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB, Bénédicte Delcoigne: None declared, Karin Ekström Smedby: None declared, Eva Baecklund: None declared, Christine Ballegaard: None declared, Pia Isomäki Speakers bureau: AbbVie, Eli Lilly and Pfizer, Consultant of: AbbVie, Eli Lilly, Pfizer, Roche and ViforPharma, Grant/research support from: Pfizer, Kalle Aaltonen: None declared, Björn Gudbjornsson Speakers bureau: Novartis, not related to this work, Consultant of: Novartis, not related to this work, Thorvardur Love Speakers bureau: Celgene, Sella Aa. Provan: None declared, Brigitte Michelsen Grant/research support from: Novartis, not related to this work, Joe Sexton: None declared, Lene Dreyer Speakers bureau: Eli Lilly, Galderma and Janssen, Grant/research support from: BMS not related to this work, Karin Hellgren: None declared

OP0262 PREVALENCE AND PREDICTORS OF ACHIEVING SUSTAINED REMISSION IN PSORIATIC ARTHRITIS

Background

Increased availability and a wide selection of b/tsDMARDs with different mode of action has made long-term remission a realistic treatment goal in psoriatic arthritis.

Objectives

To estimate the prevalence and possible predictors of sustained remission in patients with psoriatic arthritis (PsA) treated with biologic or targeted synthetic disease-modifying anti-rheumatic drugs (bDMARD/tsDMARD) in Sweden.

Methods

All patients initiating treatment with bDMARDs or tsDMARDs for PsA in Sweden and registered in the national Swedish Rheumatology Quality Register (SRQ) were included. Data on disease and treatment characteristics from the start of the first b/tsDMARD (baseline) and all registered subsequent visits were extracted from SRQ. Sustained remission (SR) was defined as DAS28-CRP ≤ 2.6, DAPSA28 ≤ 4 or the evaluator’s global assessment of disease activity (0-4 on a Likert scale) = 0, during at least two consecutive visits over at least six months. To compensate for factors that may temporarily raise disease activity measures, such as concurrent infections, one visit with higher disease activity was allowed if the treatment regimen was not altered at that point and if less than two years between adjacent visits in remission. A sensitivity analysis was performed with a more stringent SR definition, not allowing any such visits with higher disease activity. Logistic regression was used to identify possible predictors of SR.

Results

5 459 PsA patients with 50 811 visits were included in the analysis. According to DAS28-CRP, 78% of patients achieved a state of remission at some point, and 49% achieved SR at least once. When the more stringent DAPSA28 remission criteria were applied, 27% of patients reached a state of remission at some point, and 11% ever achieved SR. Corresponding figures using the evaluator’s global assessment were 64% and 34% for ever reaching remission or SR, respectively (Figure 1). The sensitivity analysis rendered similar results with a ≤3% difference from the main results for all outcomes. Higher age at start of the first b/tsDMARD therapy was associated with a lower likelihood of SR, but males were significantly more likely to achieve SR than females (OR 1,79-2,63 for reaching SR depending on the remission criteria used).

Figure 1.

Proportion of patients achieving sustained and non-sustained remission at any point after SRQ registration.

Conclusion

Despite increased availability and a wider selection of b/tsDMARDs with different modes of action, a considerable proportion of PsA patients receiving such treatments never achieve a state of remission, and less than half ever achieve a more extended period of sustained remission. Males are more likely than females to enter sustained remission.

Disclosure of Interests

Olafur Palsson: None declared, Jon Thorkell Einarsson: None declared, Johan K Wallman Consultant of: Consultancy fees from AbbVie, Amgen, Celgene, Eli Lilly and Novartis (unrelated to the present work)., Thorvardur Love: None declared, Björn Gudbjornsson Speakers bureau: Lecture fee from Amgen and Novartis (unrelated to the present work)., Meliha C Kapetanovic: None declared

Massively scaled-up testing for SARS-CoV-2 RNA via next-generation sequencing of pooled and barcoded nasal and saliva samples

Frequent and widespread testing of members of the population who are asymptomatic for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is essential for the mitigation of the transmission of the virus. Despite the recent increases in testing capacity, tests based on quantitative polymerase chain reaction (qPCR) assays cannot be easily deployed at the scale required for population-wide screening. Here, we show that next-generation sequencing of pooled samples tagged with sample-specific molecular barcodes enables the testing of thousands of nasal or saliva samples for SARS-CoV-2 RNA in a single run without the need for RNA extraction. The assay, which we named SwabSeq, incorporates a synthetic RNA standard that facilitates end-point quantification and the calling of true negatives, and that reduces the requirements for automation, purification and sample-to-sample normalization. We used SwabSeq to perform 80,000 tests, with an analytical sensitivity and specificity comparable to or better than traditional qPCR tests, in less than two months with turnaround times of less than 24 h. SwabSeq could be rapidly adapted for the detection of other pathogens.

OP0220 SECULAR TRENDS IN BASELINE CHARACTERISTICS, TREATMENT RETENTION AND RESPONSE RATES IN 17453 BIONAÏVE PSORIATIC ARTHRITIS PATIENTS INITIATING TNFI – RESULTS FROM THE EUROSPA COLLABORATION

Background:

Knowledge of changes over time in baseline characteristics and tumor necrosis factor inhibitor (TNFi) response in bionaïve psoriatic arthritis (PsA) patients treated in routine care is limited.

Objectives:

To investigate secular trends in baseline characteristics and retention, remission and response rates in PsA patients initiating a first TNFi.

Methods:

Prospectively collected data on bionaïve PsA patients starting TNFi in routine care from 15 European countries were pooled. According to year of TNFi initiation, three groups were defined a priori based on bDMARD availability: Group A (1999–2008), Group B (2009–2014) and Group C (2015–2018).

Retention rates (Kaplan-Meier), crude and LUNDEX adjusted1 remission (Disease Activity Score (DAS28) <2.6, 28-joint Disease Activity index for PsA (DAPSA28) ≤4, Clinical Disease Activity Index (CDAI) ≤2.8) and ACR50 response rates were assessed at 6, 12 and 24 months. No statistical comparisons were made.

Results:

A total of 17453 PsA patients were included (4069, 7551 and 5833 in groups A, B and C).

Patients in group A were older and had longer disease duration compared to B and C. Retention rates at 6, 12 and 24 months were highest in group A (88%/77%/64%) but differed little between B (83%/69%/55%) and C (84%/70%/56%).

Baseline disease activity was higher in group A than in B and C (DAS28: 4.6/4.3/4.0, DAPSA28: 29.9/25.7/24.0, CDAI: 21.8/20.0/18.6), and this persisted at 6 and 12 months. Crude and LUNDEX adjusted remission rates at 6 and 12 months tended to be lowest in group A, although crude/LUNDEX adjusted ACR50 response rates at all time points were highest in group A. At 24 months, disease activity and remission rates were similar in the three groups (Table).

Table 1.

Secular trends in baseline characteristics, treatment retention, remission and response rates in European PsA patients initiating a 1st TNFi

Baseline characteristicsGroup A(1999–2008)Group B(2009–2014)Group C(2015–2018)Age, median (IQR)62 (54–72)58 (49–67)54 (45–62)Male, %514847Years since diagnosis, median (IQR)5 (2–10)3 (1–9)3 (1–8)Smokers, %161717DAS28, median (IQR)4.6 (3.7–5.3)4.3 (3.4–5.1)4.0 (3.2–4.8)DAPSA28, median (IQR)29.9 (19.3–41.8)25.7 (17.2–38.1)24.0 (16.1–35.5)CDAI, median (IQR)21.8 (14.0–31.1)20.0 (13.0–29.0)18.6 (12.7–26.1)TNFi drug, % (Adalimumab / Etanercept / Infliximab / Certolizumab / Golimumab)27 / 43 / 30 / 0 / 036 / 31 / 14 / 5 / 1421 / 40 / 21 / 8 / 10Follow up6 months12 months24 monthsGr AGr BGr CGr AGr BGr CGr AGr BGr CRetention rates, % (95% CI)88 (87–89)83 (82–84)84 (83–85)79 (78–80)72 (71–73)72 (71–73)68 (67–69)60 (59–61)60 (59–62)DAS28, median (IQR)2.7 (1.9–3.6)2.4 (1.7–3.4)2.3 (1.7–3.2)2.5 (1.8–3.4)2.2 (1.6–3.1)2.1 (1.6–2.9)2.1 (1.6–3.1)2.0 (1.6–2.9)1.9 (1.5–2.6)DAPSA28, median (IQR)10.6 (4.8–20.0)9.5 (3.9–18.3)8.7 (3.6–15.9)9.1 (4.1–17.8)7.7 (3.1–15.4)7.6 (2.9–14.4)6.7 (2.7–13.7)6.6 (2.7–13.5)5.9 (2.4–11.8)CDAI, median (IQR)7.8 (3.0–15.2)8.0 (3.0–15.0)6.4 (2.6–12.2)6.4 (2.5–13.0)6.2 (2.5–12.1)5.8 (2.2–11.4)5.0 (2.0–11.0)5.5 (2.0–11.2)5.0 (2.0–9.0)DAS28 remission, %, c/L47 / 4255 / 4661 / 5153 / 4362 / 4566 / 4864 / 4268 / 3775 / 41DAPSA28 remission, %, c/L22 / 1926 / 2228 / 2325 / 2031 / 2232 / 2336 / 2334 / 1938 / 21CDAI remission, %, c/L23 / 2123 / 1926 / 2227 / 2127 / 2029 / 2134 / 2231 / 1735 / 19ACR50 response, %, c/L26 / 2322 / 1824 / 2027 / 2223 / 1721 / 1523 / 1518 / 1014 / 8

Gr, Group; c/L, crude/LUNDEX.

Conclusion:

Over the past 20 years, patient age, disease duration and disease activity level at the start of the first TNFi in PsA patients have decreased. Furthermore, TNFi retention rates have decreased while remission rates have increased, especially remission rates within the first year of treatment. These findings may reflect a greater awareness of early diagnosis in PsA patients, a lowered threshold for initiating TNFi and the possibility for earlier switching in patients with inadequate treatment response.

References:

[1]Arthritis Rheum 2006; 54: 600-6.

Acknowledgements:

Novartis Pharma AG and IQVIA for supporting the EuroSpA Research Collaboration Network.

Disclosure of Interests:

Sara Nysom Christiansen Speakers bureau: BMS and GE, Grant/research support from: Novartis, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Simon Horskjær Rasmussen: None declared, Anne Gitte Loft Speakers bureau: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, UCB, Consultant of: AbbVie, Janssen, Lilly, MSD, Novartis, Pfizer, UCB, Grant/research support from: Novartis, Johan K Wallman Consultant of: Celgene, Eli Lilly, Novartis, Florenzo Iannone Speakers bureau: Abbvie, MSD, Novartis, Pfizer and BMS, Brigitte Michelsen Consultant of: Novartis, Grant/research support from: Novartis, Michael J. Nissen Speakers bureau: Novartis, Eli Lilly, Celgene, and Pfizer, Consultant of: Novartis, Eli Lilly, Celgene, and Pfizer, Jakub Zavada: None declared, Maria Jose Santos Speakers bureau: AbbVie, Novartis, Pfizer, Manuel Pombo-Suarez: None declared, Kari Eklund: None declared, Matija Tomsic Speakers bureau: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Consultant of: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Björn Gudbjornsson Speakers bureau: Amgen and Novartis, İsmail Sari: None declared, Catalin Codreanu Speakers bureau: AbbVie, Amgen, Egis, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Amgen, Egis, Novartis, Pfizer, UCB, Daniela Di Giuseppe: None declared, Bente Glintborg Grant/research support from: Pfizer, Biogen, AbbVie, Marco Sebastiani: None declared, Karen Minde Fagerli: None declared, Burkhard Moeller: None declared, Karel Pavelka Speakers bureau: AbbVie, Roche, MSD, UCB, Pfizer, Novartis, Egis, Gilead, Eli Lilly, Consultant of: AbbVie, Roche, MSD, UCB, Pfizer, Novartis, Egis, Gilead, Eli Lilly, Anabela Barcelos: None declared, Carlos Sánchez-Piedra: None declared, Heikki Relas: None declared, Ziga Rotar Speakers bureau: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Consultant of: Abbvie, Amgen, Biogen, Medis, MSD, Novartis, Pfizer, Thorvardur Love: None declared, Servet Akar: None declared, Ruxandra Ionescu Speakers bureau: Abbvie, Amgen, Boehringer-Ingelheim Eli-Lilly,Novartis, Pfizer, Sandoz, UCB, Gary Macfarlane Grant/research support from: GlaxoSmithKline, Marleen G.H. van de Sande: None declared, Merete L. Hetland Speakers bureau: Abbvie, Biogen, BMS, Celltrion, Eli Lilly, Janssen Biologics B.V, Lundbeck Fonden, MSD, Pfizer, Roche, Samsung Biopies, Sandoz, Novartis., Mikkel Østergaard Speakers bureau: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Centocor, GSK, Hospira, Janssen, Merck, Mundipharma, Novartis, Novo, Orion, Pfizer, Regeneron, Schering-Plough, Roche, Takeda, UCB and Wyeth, Consultant of: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Centocor, GSK, Hospira, Janssen, Merck, Mundipharma, Novartis, Novo, Orion, Pfizer, Regeneron, Schering-Plough, Roche, Takeda, UCB and Wyeth

Swab-Seq: A high-throughput platform for massively scaled up SARS-CoV-2 testing

The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is due to the high rates of transmission by individuals who are asymptomatic at the time of transmission^1,2. Frequent, widespread testing of the asymptomatic population for SARS-CoV-2 is essential to suppress viral transmission. Despite increases in testing capacity, multiple challenges remain in deploying traditional reverse transcription and quantitative PCR (RT-qPCR) tests at the scale required for population screening of asymptomatic individuals. We have developed SwabSeq, a high-throughput testing platform for SARS-CoV-2 that uses next-generation sequencing as a readout. SwabSeq employs sample-specific molecular barcodes to enable thousands of samples to be combined and simultaneously analyzed for the presence or absence of SARS-CoV-2 in a single run. Importantly, SwabSeq incorporates an in vitro RNA standard that mimics the viral amplicon, but can be distinguished by sequencing. This standard allows for end-point rather than quantitative PCR, improves quantitation, reduces requirements for automation and sample-to-sample normalization, enables purification-free detection, and gives better ability to call true negatives. After setting up SwabSeq in a high-complexity CLIA laboratory, we performed more than 80,000 tests for COVID-19 in less than two months, confirming in a real world setting that SwabSeq inexpensively delivers highly sensitive and specific results at scale, with a turn-around of less than 24 hours. Our clinical laboratory uses SwabSeq to test both nasal and saliva samples without RNA extraction, while maintaining analytical sensitivity comparable to or better than traditional RT-qPCR tests. Moving forward, SwabSeq can rapidly scale up testing to mitigate devastating spread of novel pathogens.

FRI0355 IMPACT OF BIOLOGIC THERAPY ON THE INCIDENCE OF PSA AMONG PATIENTS WITH PSORIASIS

Background:

One of the strongest known risk factors for the development of psoriatic arthritis (PsA) is psoriasis. A key question is whether treatment of psoriasis may prevent or delay onset of PsA.

Objectives:

To compare the incidence of PsA among patients with psoriasis treated with a biologic compared to those treated with a non-biologic therapy for psoriasis

Methods:

We performed a retrospective cohort study in the Optum de-identified Electronic Health Record dataset between 2006-2017. Patients with two or more ICD codes for psoriasis between the ages of 16 and 90, who were initiating an oral medication, a biologic therapy, or phototherapy (defined as no preceding codes for the therapy in the prior 12 months) were identified. Covariates at baseline were determined in the 12 months prior to therapy initiation. The outcome of interest was PsA as defined by one ICD code. The incidence of PsA was described overall and within each therapy group. We analyzed the data in two ways: a) a multivariable Cox model using a time varying exposure (once the patient was exposed to a biologic, they were considered always exposed) derived from automated stepwise regression and b) propensity score matching (greedy matching, caliper 0.1) between biologic-exposed patients and oral/phototherapy exposed patients.

Results:

Among 215,386 patients with psoriasis without PsA at baseline, 9,848 were excluded for prior biologic exposure, and among the remaining, 60,258 initiated phototherapy, oral or biologic therapy during follow up. Among 22,461 new biologic initiations, 29,121 oral therapy and 8,676 phototherapy initiations, the mean age was lower in the biologics group compared to the non-biologic groups (46.9 vs 50.8), with a similar proportion of females and Caucasians. Observational time was also similar. A total of 1,643, 1,813, and 122 new PsA cases occurred over 60,739, 85,670, and 28,528 person/years (PY) of follow up, respectively (incidence 27.1, 21.2 and 4.2 per 1,000 person years respectively). Using a traditional multivariable adjustment approach with time varying exposure, the age and sex adjusted and fully adjusted HR (95% CI) for biologic users were 1.01 (0.99-1.04) and 0.93 (0.91-0.95), respectively. However, after propensity score matching, the HR (95% CI) was 1.64 (1.51-1.77). Survival curves cross, however, at approximately 8 years (Figure 1) and most of the new diagnoses of PsA occurred shortly after therapy initiation (Figure 2).

Conclusion:

Confounding by indication or protopathic bias may explain the observed association of biologic therapy with the development of PsA among patients with psoriasis. Some patients may be receiving therapy because they have both psoriasis and early symptoms of PsA or their PsA diagnosis is not recorded appropriately. Given the directional discrepancy in the results between traditional modeling and propensity score analysis, further work is needed to understand the nature of this relationship.

Figure

Figure 3.

Directed Acyclic Graphdescribing potential confounders in relationship between therapy prescription and diagnosis of PsA

Disclosure of Interests:

Alexis Ogdie Grant/research support from: Pfizer, Novartis, Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Janssen, Lilly, Pfizer, Novartis, Thorvardur Love: None declared, Junko Takeshita: None declared, Joel Gelfand Grant/research support from: grants (to the Trustees of the University of Pennsylvania) from Abbvie, Boehringer Ingelheim, Janssen, Novartis Corp, Celgene, Ortho Dermatologics, and Pfizer Inc., Consultant of: BMS, Boehringer Ingelheim, Janssen Biologics, Novartis Corp, UCB (DSMB), Neuroderm (DSMB), Dr. Reddy’s Labs, Pfizer Inc., and Sun Pharma, Paid instructor for: received payment for continuing medical education work related to psoriasis that was supported indirectly by Lilly, Ortho Dermatologics and Novartis., Jose Scher Consultant of: Novartis, Janssen, UCB, Sanofi., Hyon Choi Grant/research support from: Ironwood, Horizon, Consultant of: Takeda, Selecta, Horizon, Kowa, Vaxart, Ironwood, Robert Fitzsimmons: None declared, Christopher T. Ritchlin Grant/research support from: UCB Pharma, AbbVie, Amgen, Consultant of: UCB Pharma, Amgen, AbbVie, Lilly, Pfizer, Novartis, Gilead, Janssen, Joseph F. Merola Consultant of: Merck, AbbVie, Dermavant, Eli Lilly, Novartis, Janssen, UCB Pharma, Celgene, Sanofi, Regeneron, Arena, Sun Pharma, Biogen, Pfizer, EMD Sorono, Avotres and LEO Pharma

SAT0430 SECUKINUMAB EFFECTIVENESS IN 1543 PATIENTS WITH PSORIATIC ARTHRITIS TREATED IN ROUTINE CLINICAL PRACTICE IN 13 EUROPEAN COUNTRIES IN THE EuroSpA RESEARCH COLLABORATION NETWORK

Background:

There is a lack of real-life evidence on secukinumab effectiveness in psoriatic arthritis (PsA) patients.

Objectives:

To assess the real-life 6- and 12-month secukinumab retention rates and proportions of patients in remission/low disease activity (LDA) overall, and by prior biologic disease-modifying anti-rheumatic drug (bDMARD)/targeted synthetic (ts)DMARD use.

Methods:

Data from PsA patients treated with secukinumab in routine care from 13 countries in the European Spondyloarthritis (EuroSpA) Research Collaboration Network were pooled. Patients started secukinumab ≥12 months before date of datacut. Crude and LUNDEX adjusted (crude value adjusted for drug retention) 28-joint Disease Activity index for PSoriatic Arthritis (DAPSA28) and 28-joint Disease Activity Score with CRP (DAS28CRP) remission and LDA rates were calculated. Group comparisons between b/tsDMARD naïve, 1 prior and ≥2 prior b/tsDMARD users were done with ANOVA, Kruskal-Wallis, Chi-square or Kaplan-Meier analyses with log-rank test, as appropriate.

Results:

A total of 1543 PsA patients were included (Table 1). b/tsDMARD naïve patients had shorter time since diagnosis, higher baseline disease activity, a higher proportion were men and a higher proportion achieved remission. Overall 6/12-month secukinumab retention rates were 86%/74% and significantly higher in b/tsDMARD naïve patients at 12, but not 6 months (Table 2, Figure). Overall, crude 6- and 12-month DAPSA28≤4/DAS28CRP<2.6 were achieved by 13%/34% and 11%/39% of the patients, respectively.

Table 1.All patients (n=1543)b/tsDMARD naïve (n=287)1 prior b/tsDMARD (n=333)≥2 prior b/tsDMARDs (n=923)p *Age (years), mean (SD)52 (11)49 (12.3)51 (11)53 (11)<0.001Male, %42%49%46%39%0.003Years since diagnosis, mean (SD)9 (8)7 (8)8 (7)10 (8)<0.001Current smokers, %19%21%22%18%0.23CRP (mg/L), median (IQR)5 (2-12)7 (2-19)4 (2-8)5 (2-11)<0.001DAPSA28, median (IQR)26 (18-37)28 (19-38)22 (13-32)27 (19-38)<0.001DAS28CRP, median (IQR)4.2 (3.3-5.0)4.4 (3.5-5.2)3.8 (2.6-4.5)4.2 (3.4-5.0)<0.001

*Comparisons across number of prior b/tsDMARD were done with ANOVA, Kruskal-Wallis or Chi-square test, as appropriate

Table 2.MonthsAll patients (n=1543)b/tsDMARD naïve (n=287)1 prior b/tsDMARD (n=333)≥2 prior b/tsDMARDs (n=923)p *Secukinumab retention rate, % (95%CI)686% (84-87%)89% (86-93%)85% (81-89%)85% (82-87%)0.111274% (72-76%)81% (76-86%)76% (71-80%)72% (69-75%)0.006DAPSA28≤4 Crude613%25%11%11%<0.001 LUNDEX11%22%9%9%<0.001 Crude1211%22%11%8%<0.001 LUNDEX7%17%7%5%0.001DAS28CRP<2.6 Crude634%51%33%30%<0.001 LUNDEX29%45%27%24%<0.001 Crude1239%55%41%34%<0.001 LUNDEX26%41%27%21%<0.001DAPSA28 >4 and ≤14 Crude633%42%32%30%0.04 LUNDEX27%37%27%25%0.02 Crude1235%48%36%32%0.009 LUNDEX24%36%24%20%0.004DAS28CRP ≤3.2 Crude652%69%53%47%<0.001 LUNDEX43%61%45%38%<0.001 Crude1255%72%55%50%<0.001 LUNDEX37%54%37%32%<0.001

*Comparisons across number of prior b/tsDMARDs were done with Kaplan-Meier with log-rank test or Chi-Square test, as appropriate

Conclusion:

In this real-life study of 1543 patients with PsA in 13 European countries 12-month secukinumab retention was high, and significantly higher for b/tsDMARD naïve patients. Overall, a higher proportion of bionaïve than previous b/tsDMARD users achieved remission, regardless of remission criteria.

Acknowledgments:

Novartis and IQVIA for supporting the EuroSpA RCN

Disclosure of Interests:

Brigitte Michelsen Grant/research support from: Research support from Novartis, Consultant of: Consulting fees Novartis, Stylianos Georgiadis Grant/research support from: Novartis, Daniela Di Giuseppe: None declared, Anne Gitte Loft Grant/research support from: Novartis, Consultant of: AbbVie, MSD, Novartis, Pfizer and UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer and UCB, Michael Nissen Grant/research support from: Abbvie, Consultant of: Novartis, Lilly, Abbvie, Celgene and Pfizer, Speakers bureau: Novartis, Lilly, Abbvie, Celgene and Pfizer, Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Manuel Pombo-Suarez Consultant of: Janssen, Lilly, MSD and Sanofi., Speakers bureau: Janssen, Lilly, MSD and Sanofi., Heřman Mann: None declared, Ziga Rotar Consultant of: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Speakers bureau: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Kari Eklund Consultant of: Celgene, Lilly, Speakers bureau: Pfizer, Roche, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Maria Jose Santos Speakers bureau: Novartis and Pfizer, Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Catalin Codreanu Consultant of: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Speakers bureau: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Sema Yilmaz: None declared, Johan K Wallman Consultant of: AbbVie, Celgene, Eli Lilly, Novartis and UCB Pharma, Cecilie Heegaard Brahe Grant/research support from: Novartis, Burkhard Moeller: None declared, Ennio Giulio Favalli Consultant of: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Speakers bureau: Consultant and/or speaker for BMS, Eli-Lilly, MSD, UCB, Pfizer, Sanofi-Genzyme, Novartis, and Abbvie, Carlos Sánchez-Piedra: None declared, Lucie Nekvindova: None declared, Matija Tomsic: None declared, Nina Trokovic: None declared, Eirik kristianslund: None declared, Helena Santos Speakers bureau: AbbVie, Eli-Lilly, Janssen, Pfizer, Novartis, Thorvardur Love: None declared, Ruxandra Ionescu Consultant of: Consulting fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Speakers bureau: Consulting and speaker fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Yavuz Pehlivan: None declared, Gareth T. Jones Grant/research support from: Pfizer, AbbVie, UCB, Celgene and GSK., Irene van der Horst-Bruinsma Grant/research support from: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Consultant of: AbbVie, Novartis, Eli Lilly, Bristol-Myers Squibb, MSD, Pfizer, UCB Pharma, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis

OP0213 THE IMPACT OF TNFΑ INHIBITORS ON GLUCOCORTICOIDS USE AMONG PATIENTS WITH ARTHRITIS

Background:

Glucocorticoid steroid (GC) use among patients with arthritis is common. The introduction of TNFα inhibitors (TNFi) has been a breakthrough in the treatment of arthritis leading to remission for many patients. However, there is scarce information on the impact of TNFi on the use of GC among patients with inflammatory joint diseases.

Objectives:

To explore oral GC use in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (axSpA) before and after the initiation of TNFi therapy. Furthermore, to evaluate if patients on long term GC treatment were receiving active preventive osteoporosis treatment and how treatment with TNFi affected the use of topical steroids in patients with PsA.

Methods:

Clinical data on patients with RA, PsA and axSpA who initiated TNFi therapy with etanercept, infliximab, adalimumab or golimumab for the first time between 2005-2015 was collected from the ICEBIO registry. ICEBIO is a nationwide registry on all patients treated with biologics for rheumatologic disorders in Iceland. The use of oral GC, topical steroids and bisphosphonates was collected from the Icelandic Prescription Medicines Registry (IPMR) for a period of four years, two years before and after the initiation of TNFi. Medication use was then evaluated by counting the number of individuals receiving a medication in a given year, the total number of prescriptions, and the defined daily dose (DDD). Five controls were randomly selected from IPMR and matched on age, sex and time frame.

Results:

621 patients with RA, PsA or axSpA received 2630 prescriptions (4.2 prescription per patient; 3105 controls received 1337 prescriptions or 0.4 prescription per individual) for GC during the study period. GC use varied between patient groups (Figure 1). The total GC use (DDD) doubled over the two-year period leading up to TNFi treatment but decreased sharply after the initiation of TNFi. The number of individuals on GC decreased by one third after initiating TNFi therapy and the majority of those who continued GC treatment were patients with RA (Figure 1). Of those patients on long term GC treatment (>7.5 mg/day for three months) 38% were receiving bone protective therapy against corticosteroid induced osteoporosis. The use of topical steroids decreased by half among PsA patients and one third discontinued the treatment after initiating TNFi (Figure 2).

Conclusion:

TNFi therapy does impact GC use among patients with arthritides, however a large portion of RA patients are still on GC two years after initiating TNFi therapy. Better osteoporosis prophylaxis and treatment is warranted for those patients on long term GC

Disclosure of Interests:

Rebekka Hafthorsdottir: None declared, Anna Gunnarsdottir: None declared, Thorvardur Love: None declared, Gerdur Gröndal: None declared, Björn Gudbjornsson Speakers bureau: Novartis and Amgen

OP0088 INITIATING TNF INHIBITORS IN INFLAMMATORY ARTHRITIS DOES NOT DECREASE THE AVERAGE OPIOID ANALGESIC CONSUMPTION

Background:

TNFα-inhibitor (TNFi) therapy is effective in controlling several rheumatic diseases and has been shown to reduce pain in patients with arthritis. Opioids are often prescribed for chronic pain, a common issue in inflammatory joint disease.

Objectives:

To explore the impact of the initiation of TNFi therapy as a first-line biologic disease-modifying anti-rheumatic drug (DMARD) on the prescription rates of opioids in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and undifferentiated arthritis (UA) in Iceland.

Methods:

All patients receiving biologic DMARD therapy for rheumatic diseases in Iceland are registered in a nationwide database (ICEBIO). The Icelandic Directorate of Health operates a Prescription Medicines Register that includes over 90% of all drug prescriptions in Iceland. The study group included patients with RA, PsA, AS, and UA registered in ICEBIO and for each of them five randomly selected comparators from the general population matched on age, sex, and calendar time. On February 1st2016 we extracted data on all filled opioid analgesic prescriptions two years before and two years after the date of TNFi initiation.

Results:

Data from 359 RA, 217 AS, 251 PsA and 113 UA patients and 4700 comparators were collected. In total, 75% of patients compared to 43% of comparators received ≥1 opiate prescription during the study period. The proportion of patients using opioids (regardless of dose) two years prior to TNFi initiation was 41%, increasing to 49% the following year. After TNFi initiation the proportion returned to 40% (Figure 1). Despite this, the mean yearly opiate dose used by the patients followed a rising trajectory throughout the study period (Figure 2). In total, patients were prescribed nearly 6 times more opioids than the comparators, corresponding to a bootstrapped mean (95% CI) dose of 818 (601-1073) mg MED per patient and year compared to 139 (111-171) mg for comparators.

Figure 1.

Percental distributions of opioid analgesic use by dose (according to dispensed prescriptions) among patients with inflammatory arthritis (A) and matched comparators (B). All doses are oral morphine equivalent dose (MED) in milligrams.

Figure 2.

Bootstrapped mean oral morphine equivalent dose per person per year for patients with inflammatory arthritis (above) and age and sex matched comparators (below). Box edges represent 25-75thpercentiles and whiskers 95% confidence intervals.

Conclusion:

Three out of four patients with inflammatory arthritis in Iceland use opioid analgesics in the two years prior to and/or after the initiation of TNFi therapy and the mean doses were significantly higher than in matched comparators. The proportion of patients receiving opioids increased before TNFi therapy and then decreased again to the previous level. The initiation of the first-line TNFi did not reduce opioid consumption by dose at the group level. On the contrary, there was a trend towards increasing doses over time in both patients and comparators, possibly reflecting the development of opiate tolerance.

Table 1.

Baseline demographic data. Mean ± SD unless specified. * defined from diagnosis to basel

All patientsRheumatoid arthritisPsoriatic arthritisAnkylosing spondylitisUndifferentiated arthritisTotal n (%)940 (100)359 (38)251 (27)217 (23)113 (12)Age (years)49 ± 1453 ± 1449 ± 1343 ± 1344 ± 15Disease duration (years)*7.8 ± 8.58.2 ± 8.27.4 ± 7.88.3 ± 10.26.3 ± 6.6Female58%73%59%34%52%

Disclosure of Interests:

Olafur Palsson: None declared, Thorvardur Love: None declared, Johan K Wallman Consultant of: Consultant for AbbVie, Celgene, Eli Lilly, Novartis and UCB Pharma., Meliha C Kapetanovic: None declared, Petur S Gunnarsson: None declared, Björn Gudbjornsson Speakers bureau: Novartis and Amgen

THU0394 COMPARISON OF TREATMENT RETENTION OF SECUKINUMAB AND TNF-INHIBITORS IN PSORIATIC ARTHRITIS. OBSERVATIONAL DATA FROM A NORDIC COLLABORATION

Background:

A head-to-head trial (EXCEED) has indicated similar effectiveness of secukinumab (SEC) and the tumor necrosis factor inhibitor (TNFi) adalimumab (ADA) in psoriatic arthritis (PsA). In the clinical setting, treatment retention serves as a combined measure of overall effectiveness and tolerability.

Objectives:

To explore baseline patient characteristics, and compare treatment retention rates for SEC and each of etanercept (ETN), infliximab (IFX), golimumab (GOL), certolizimab (CZP) and ADA in PsA.

Methods:

Patients starting SEC or any TNFi in 2015-2018, in the 5 Nordic countries, were identified in clinical rheumatology registers. Data were pooled for analysis and stratified by 1st, 2ndand ≥3rdline of treatment. One year treatment retention was compared by crude Kaplan-Meier curves and a proportional hazard model for risk of discontinuation, censored at 1 year and adjusted for sex, age, country and baseline CRP, patient global and use of csDMARD, with ADA as reference.

Results:

In total, 6062 patients with PsA were included, contributing 8172 treatment starts (table 1). SEC was mainly used as 2ndor ≥3rdline treatment. The survival curves and 1-year treatment retention rates, stratified by line of treatment, were similar for SEC compared to the TNFis, with some differences between the different TNFi (fig 1, table 2). Adjusted hazard ratios (HR) also indicated similar risk of SEC withdrawal compared to ADA (table 2).

Table 1.

Patient characteristics at treatment start

1stline2ndline≥3rdlineSECN=164TNFiN=3808SECN=273TNFiN=1767SECN=767TNFiN=1393Females48%47%44%42%36%39%Age, years52 (13)49 (13)50 (12)50 (13)52 (12)51 (12)Disease duration, years12 (10)10 (10)13 (10)13 (10)16 (10)16 (10)Swollen joint count 283 (4)2 (3)2 (3)2 (3)3 (4)2 (3)CRP, mg/L10 (18)10 (17)7 (11)9 (17)13 (22)11 (20)Patient global score57 (24)58 (24)60 (25)59 (26)68 (23)65 (24)Concomitant therapycsDMARD30%60%41%57%49%53% Methotrexate24%49%31%48%40%44% Sulphasalazine2%9%5%5%4%6%

Numbers are mean (SD) unless noted otherwise

Table 2.

One year treatment retention and hazard of discontinuation for SEC and TNFi

Line of treatmentDrugN1 year treatment retention % (95% CI)Adjusted HR (95% CI) for discontinuation1stlineADA56973 (69-76)RefCZP27366 (60-72)1.2 (0.9-1.6)ETN174773 (71-75)0.9 (0.7-1.1)GOL21267 (60-73)1.2 (0.9-1.7)IFX100762 (59-65)1.4 (1.1-1.7)SEC16472 (63-78)1.0 (0.7-1.4)2ndlineADA41569 (63-73)RefCZP17651 (43-58)1.6 (1.2-2.2)ETN70163 (59-66)1.2 (0.9-1.5)GOL15169 (61-76)0.9 (0.6-1.2)IFX32465 (59-70)1.0 (0.8-1.4)SEC27369 (62-74)0.9 (0.7-1.2)≥3rdlineADA34667 (62-72)RefCZP22149 (42-56)1.5 (1.2-2.0)ETN37262 (57-67)1.1 (0.9-1.5)GOL20656 (49-63)1.3 (1.0-1.8)IFX24857 (50-63)1.3 (1.0-1.8)SEC76763 (59-67)1.0 (0.8-1.3)

Conclusion:

In this large study of bDMARD treatment of PsA in clinical practice, SEC was most often used as 2ndor ≥3rdline treatment, and the treatment retention of SEC was comparable with that of TNFi. Further analyses, taking into account other comorbidities, channeling and effectiveness will be presented.

Acknowledgments:

UL and BG are shared first, and LJ and LEK shared last authors.

Partly funded by Nordforsk and FOREUM.

Disclosure of Interests:

Ulf Lindström: None declared, Bente Glintborg Grant/research support from: Grants from Pfizer, Biogen and Abbvie, Daniela Di Giuseppe: None declared, Tanja Schjødt Jørgensen Speakers bureau: Abbvie, Pfizer, Roche, Novartis, UCB, Biogen, and Eli Lilly

, Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Kathrine L. Grøn Grant/research support from: BMS, Sella Aarrestad Provan Consultant of: Novartis, Brigitte Michelsen: None declared, Merete L. Hetland Grant/research support from: BMS, MSD, AbbVie, Roche, Novartis, Biogen and Pfizer, Consultant of: Eli Lilly, Speakers bureau: Orion Pharma, Biogen, Pfizer, CellTrion, Merck and Samsung Bioepis, Johan K Wallman Consultant of: AbbVie, Celgene, Eli Lilly, Novartis and UCB Pharma, Dan Nordström Consultant of: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Speakers bureau: Abbvie, Celgene, Lilly, Novartis, Pfizer, Roche and UCB., Nina Trokovic: None declared, Thorvardur Love: None declared, Niels Steen Krogh: None declared, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma, Lennart T.H. Jacobsson Consultant of: AbbVie, Eli Lilly, Janssen, Novartis and Pfizer, Lars Erik Kristensen Consultant of: UCB Pharma (Advisory Board), Sannofi (Advisory Board), Abbvie (Advisory Board), Biogen (Advisory Board), Speakers bureau: AbbVie, Amgen, Biogen, Bristol-Myers Squibb,Celgene, Eli Lilly, Gilead, Forward Pharma, Janssen Pharmaceuticals, MSD, Novartis, Pfizer, and UCB Pharma

FRI0283 CO-MEDICATION WITH CSDMARD HAS LITTLE EFFECT ON THE RETENTION OF TNF INHIBITORS IN PSORIATIC ARTHRITIS, RESULTS FROM THE EUROSPA COLLABORATION

Background:

Previous studies have suggested similar effectiveness, but longer treatment retention, for tumor necrosis factor inhibitors (TNFi), when used in combination with a conventional synthetic disease modifying anti-rheumatic drug (csDMARD) in psoriatic arthritis (PsA).

Objectives:

To describe patients with PsA initiating a first TNFi as monotherapy compared to combination therapy, and to explore 1-year treatment retention of TNFi in the two groups.

Methods:

Patients with PsA starting a first TNFi (2006-2017) were identified in biologics registers of 13 European countries, and data were pooled for analysis. Co-medication with csDMARD was determined at TNFi start.

Because of large inter-country variation in TNFi retention, countries were split into two strata, depending on each country’s 1-year retention rate for TNFi being above (stratum A) or below (stratum B) the average 1-year retention rate.

TNFi treatment retention was compared through Kaplan-Meier curves; the proportion remaining on the TNFi at one year; and hazard ratios (HR) during the first year: (i) crude; adjusted for (ii) country-strata, and (iii) country-strata, sex, age, calendar year, DAS28 and disease duration. In model (iii) only registers contributing >1000 patients or <33% missing data for DAS28 were included.

Results:

A total of 14778 patients with PsA starting a first TNFi were included. Baseline disease activity was similar within stratum B, but higher for the combination treatment group in stratum A (table 1).

Table 1.

Baseline characteristics

Country strataStratum AStratum BTNFimonotherapyN=2120TNFi/csDMARDcombinationN=2128TNFimonotherapyN=3369TNFi/csDMARDcombinationN=7161Females52%51%53%51%Age, years49.7 (12.2)48.7 (11.8)48.8 (13.0)48.9 (12.2)Disease duration, yrs6.4 (7.0)6.8 (6.8)5.9 (7.5)5.9 (7.1)Tender joints 285.5 (6.3)8.0 (6.3)5.6 (6.0)5.6 (5.7)Swollen joints 282.8 (4.3)5.6 (5.0)3.0 (3.8)3.3 (3.8)VAS pain54 (29)62 (24)59 (23)56 (24)DAPSA-2824.6 (18.6)36.2 (17.6)27.3 (15.6)27.2 (15.2)DAS28 (CRP)3.5 (1.4)4.7 (1.3)4.0 (1.2)4.0 (1.1)Concomitant csDMARDMethotrexate-76%-79%Sulfasalazine-15%-15%Other csDMARD-49%-25%

Numbers are means (sd) unless otherwise stated.

The Kaplan-Meier curves for the treatment groups were similar within each stratum (fig 1), as were the proportions remaining on TNFi after one year, stratum A: monotherapy 86% (95%CI: 85-88) vs. combination 86% (84-87), stratum B: 71% (69-72) vs. 73% (72-74). The HRs for TNFi discontinuation (ref=TNFi monotherapy) were: (i) 1.06 (0.98-1.13), (ii) 0.94 (0.87-1.01), (iii) 0.89 (0.83-0.96), including 13078 patients (9 countries) for model (iii).

Conclusion:

In this exploratory study no benefit in TNFi retention was observed for csDMARD combination therapy in crude analyses, while in adjusted analyses an 11% lower risk of TNFi discontinuation was found. These preliminary results offer limited support for use of combination therapy in PsA. Further analyses will explore to what extent the results are affected by inter-country heterogeneity and differences between TNFi.

Acknowledgments:

UL and DDG contributed equally.

Novartis Pharma AG and IQVIA support the EuroSpA collaboration.

Disclosure of Interests:

Ulf Lindström: None declared, Daniela Di Giuseppe: None declared, Bénédicte Delcoigne: None declared, Bente Glintborg Grant/research support from: Grants from Pfizer, Biogen and Abbvie, Burkhard Moeller: None declared, Manuel Pombo-Suarez Consultant of: Janssen, Lilly, MSD and Sanofi., Speakers bureau: Janssen, Lilly, MSD and Sanofi., Carlos Sánchez-Piedra: None declared, Kari Eklund Consultant of: Celgene, Lilly, Speakers bureau: Pfizer, Roche, Heikki Relas Grant/research support from: Abbvie., Consultant of: Abbvie, Celgene, and Pfizer., Speakers bureau: Abbvie, Celgene, and Pfizer., Björn Gudbjornsson Speakers bureau: Novartis and Amgen, Thorvardur Love: None declared, Gareth T. Jones Grant/research support from: Pfizer, AbbVie, UCB, Celgene and GSK., Adrian Ciurea Consultant of: Consulting and/or speaking fees from AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly, Merck Sharp & Dohme, Novartis and Pfizer., Catalin Codreanu Consultant of: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Speakers bureau: Speaker and consulting fees from AbbVie, Accord Healthcare, Alfasigma, Egis, Eli Lilly, Ewopharma, Genesis, Mylan, Novartis, Pfizer, Roche, Sandoz, UCB, Ruxandra Ionescu Consultant of: Consulting fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Speakers bureau: Consulting and speaker fees from Abbvie, Eli-Lilly, Novartis, Pfizer, Roche, Sandoz, Lucie Nekvindova: None declared, Jakub Zavada Speakers bureau: Abbvie, UCB, Sanofi, Elli-Lilly, Novartis, Zentiva, Accord, Nuh Atas: None declared, Servet Yolbaş: None declared, Karen Fagerli: None declared, Brigitte Michelsen Grant/research support from: Research support from Novartis, Consultant of: Consulting fees Novartis, Ziga Rotar Consultant of: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Speakers bureau: Speaker and consulting fees from Abbvie, Amgen, Biogen, Eli Lilly, Medis, MSD, Novartis, Pfizer, Roche, Sanofi., Matija Tomsic: None declared, Florenzo Iannone Consultant of: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Speakers bureau: Speaker and consulting fees from AbbVie, Eli Lilly, Novartis, Pfizer, Roche, Sanofi, UCB, MSD, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Pedro Ávila-Ribeiro Grant/research support from: Novartis, Lykke Midtbøll Ørnbjerg Grant/research support from: Novartis, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Lennart T.H. Jacobsson Consultant of: AbbVie, Eli Lilly, Janssen, Novartis and Pfizer, Johan Askling Grant/research support from: JA acts or has acted as PI for agreements between Karolinska Institutet and the following entities, mainly in the context of the ARTIS national safety monitoring programme of immunomodulators in rheumatology: Abbvie, BMS, Eli Lilly, Merck, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB Pharma, Michael Nissen Grant/research support from: Abbvie, Consultant of: Novartis, Lilly, Abbvie, Celgene and Pfizer, Speakers bureau: Novartis, Lilly, Abbvie, Celgene and Pfizer

Use of comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys to investigate the role of nonmodifiable factors in determining ultimate renal function

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Background: Factors that determine renal function after partial nephrectomy (PN) are not well defined, including the impact of cold vs. warm ischemia and the relative importance of modifiable and non-modifiable factors. We studied these determinants in a large cohort of patients with a solitary functioning kidney undergoing PN.

Methods: In 1980–2009, 660 PN were performed at 4 centers for tumor in a solitary-functioning kidney under cold (n=300) or warm (n=360) ischemia. Data were collected in IRB-approved registries; follow- up averaged 4.5 years. Pre- and postoperative glomerular filtration rates (GFR) were estimated via CKD-EPI equation.

Results: At 3 months after PN, median GFR decreased by equivalent amounts with cold or warm ischemia (21% vs. 22%, respectively, p=0.7) although median cold ischemic times were much longer (45 vs. 22 min. respectively, p<0.001). In multivariable analyses, increasing age, larger tumor size, lower preoperative GFR, and longer ischemia time were associated with decreased postoperative GFR (p<0.05). When percentage of parenchyma spared was incorporated into the analysis, this factor and preoperative GFR proved to be the primary determinants of ultimate renal function, and duration of ischemia lost statistical significance.

Conclusions: This non-randomized comparative study suggests that long-term renal function after PN is determined primarily by the quantity and quality of renal parenchyma that can be preserved. Within the relatively strict parameters of conventional practice, i.e. predominantly short ischemic intervals and liberal use of hypothermia, ischemia time was not an independent predictor of ultimate renal function after PN. Nevertheless, type and duration of ischemia remain the most important modifiable factors during PN, and mandate further study.

[Table: see text]

Control, compare and communicate: designing control charts to summarise efficiently data from multiple quality indicators

Summarising the complex data generated by multiple cross sectional quality indicators in a way that patients, clinicians, managers and policymakers find useful is challenging. A common approach is aggregation to create summary measures such as star ratings and balanced score cards, but these may conceal the detail needed to focus quality improvement. We propose an alternative way of summarising and presenting multiple quality indicators, suitable for use for quality improvement and governance. This paper discusses (1) control charts for repeated measurements of single processes as used in industrial statistical process control (SPC); (2) control charts for cross sectional comparison of many institutions for a single quality indicator (rarely used in industry but commonly proposed for health care); and (3) small multiple graphics which combine control chart signal extraction with efficient graphical presentations for multiple indicators.

Speed of lexical activation in nonfluent Broca's aphasia and fluent Wernicke's aphasia

Rapid, automatic access to lexical/semantic knowledge is critical in supporting the tight temporal constraints of on-line sentence comprehension. Based on findings of "abnormal" lexical priming in nonfluent aphasics, the question of disrupted automatic lexical activation has been the focus of many recent efforts to understand their impaired sentence comprehension capabilities. The picture that emerges from this literature is, however, unclear. Nonfluent Broca's aphasic patients show inconsistent, not absent, lexical priming, and there is little consensus about the conditions under which they do and do not prime. The most parsimonious explanation for the variable findings from priming studies to date is that the primary disturbance in Broca's lexical activation has something to do with speed of activation. Broca's aphasic patients prime when sufficient time is allowed for activation to spread among associates. To examine this "slowed activation" hypothesis, the time course of lexical activation was examined using a list priming paradigm. Temporal delays between successive words ranged from 300 to 2100 msec. One nonfluent Broca's aphasic patient and one fluent Wernicke's patient were tested. Both patients displayed abnormal priming patterns, though of different sorts. In contrast to elderly subjects, who prime at relatively short interstimulus intervals (ISIs) beginning at 500 msec, the Broca's aphasic subject showed reliable automatic priming but only at a long ISI of 1500 msec. That is, this subject retained the ability to access lexical information automatically if allowed sufficient time to do so, a finding that may help explain disrupted comprehension of normally rapid conversational speech. The Wernicke's aphasic subject, in contrast, showed normally rapid initial activation but continued to show priming over an abnormally long range of delays, from 300 msec through 1100 msec. This protracted priming suggests failure to dampen activation and might explain the semantic confusion exhibited by fluent Wernicke's patients.

Coreference processing and levels of analysis in object-relative constructions; demonstration of antecedent reactivation with the cross-modal priming paradigm

This paper is concerned with two related issues in sentence processing--one methodological and one theoretical. Methodologically, it provides an unconfounded test of the ability of the cross-modal lexical priming task, when used appropriately, to provide detailed evidence about the time-course of antecedent reactivation during sentence processing. Theoretically, it provides a study of the nature of the representation that is examined when a reference-seeking element is linked to its antecedent during the processing of object-relative clause constructions. In these studies, subjects heard sentences which contained a lexical ambiguity placed in a strong biasing context. In one study this ambiguous word was the "moved" or "fronted" object of the verb in an object-relative construction. A cross-modal lexical priming (CMLP) naming task was used to determine whether one or more of the meanings of the ambiguity are activated at three temporally distinct points during the sentence: (1) immediately after the lexical ambiguity (Study 1); (2) a later point that was 700 milliseconds before the offset of the main verb (Study 2); (3) immediately after this main verb (at the gap in this filler-gap construction) (Study 2). The probes in the CMLP task were controlled for potential confounds. The results demonstrate the following: At Test Point 1, all meanings of the ambiguity were activated; at Test Point 2, neither meaning of the ambiguity was (still) activated; at Test Point 3, only a single (context-relevant) meaning of the ambiguity was reactivated. It is concluded that an underlying (deep; non-surface-level) memorial representation of the sentence is examined during the process of linking an antecedent to a structural position requiring a referent, and that the CMLP task provides an unbiased measure of this reactivation. Further, it is concluded that this effect cannot be accounted for under a "compound cue" (Ratcliff & McKoon, 1994) explanation.

Functional localization in the brain with respect to syntactic processing

This report describes some recent examinations of the ability of aphasic patients to construct syntactically governed dependency relations in real time. The data show that Wernicke's patients can link the elements of dependency relations in the same way as neurologically intact subjects, even for sentences that they do not understand. Broca's patients, by contrast, are shown to be unable to create such links, even for sentences that they do understand. These data underline the isolability of this stage of syntactic analysis and they suggest that comprehension limitations statable in syntactic terms can be traced to changes in cortically localizable processing resources.

Potential impact of pulmonary artery catheter placement on short-term management decisions in the medical intensive care unit

The purpose of this study was to examine the potential impact of pulmonary artery (PA) catheter placement on short-term management decisions in the medical intensive care unit (ICU). One hundred three patients were examined over an 18-month period. The predominant indications for PA-catheter placement included refractory congestive heart failure, airspace disease, uncertain cardiac filling pressures, or hypotension. In 58 (56%) of the 103 patients, management recommendations changed as a direct result of knowledge gained by PA catheter placement. These changes involved fluid therapy recommendations in 41 patients, vasopressor use in 17 patients, intravenous vasodilator use in 24 patients, and recommendations for the use of inotropic agents in 15 patients. Although 18 patients experienced early or late complications, major events were limited to a single pneumothorax requiring chest tube insertion and four episodes of bacteremia. No deaths were directly attributable to the catheter insertion. In critically ill patients in the medical intensive care unit, PA-catheter placement leads to changes in recommendations for management in a substantial portion of patients with little risk of life-threatening complications in those who receive such invasive monitoring.

Intussusception: a supplement to the mnemonic for coma

Expected clinical manifestations of intussusception include paroxysmal abdominal pain, vomiting, abdominal mass, and with time, rectal bleeding. We report a case where lethargy and vomiting are the presenting complaints. Diagnostic delay was encountered for this infant who had altered sensorium without accompanying pain, melena, or mass on initial examination. Either plain radiographs, supplemented by ultrasonography of the abdomen, or a barium enema should be performed in infants with unexplained lethargy.

Treatment of bacterial prostatitis. Comparison of cephalexin and minocycline

The relative safety and efficacy of minocycline and cephalexin were examined in patients with acute or chronic prostatitis. The multicenter study was of single-blind, parallel-group design. Forty-two men received minocycline (200-mg initial dose followed by 100 mg twice daily) and 44, cephalexin (500 mg four times daily); each antibiotic was administered orally for four weeks. A follow-up period of patient assessment extended for an additional six weeks. Evaluable data were available for 20 minocycline-treated patients and for 24 cephalexin-treated patients. Clinical cure or improvement without recurrence was seen in 65 per cent of the patients who received minocycline and in 46 per cent of those given cephalexin. Bacteriologic cure without relapse or reinfection occurred in 45 per cent of the minocycline-treated men and in 21 per cent of the cephalexin-treated men. Serious adverse clinical experiences were not encountered in either treatment group. Although several factors, mainly the small number of patients, precluded a statistical analysis of comparative efficacy, it was evident that more patients in the minocycline-treated group had both clinical and bacteriologic cures (35%) than did those in the cephalexin-treated group (21%).

Methotrexate resistant cells as targets for selective chemotherapy

Strategies that are selective for eradicating methotrexate resistant cells are described. These strategies have been developed based on knowledge of the mechanism of drug resistance encountered in experimental systems and in the clinic. Drug resistance to methotrexate in experimental tumors is commonly due to either gene amplification (dihydrofolate reductase) or to impaired transport of methotrexate. While no effective drugs or methods to prevent gene amplification have been described, the concept of developing "pro drugs", i.e. a drug that is selectively reduced by dihydrofolate reductase to an inhibitor of another critical folate enzyme (thymidylate synthase, methionine synthetase, folylpolyglutamate synthetase) remains worthwhile. Second generation antifolates such as trimetrexate which are effective vs methotrexate transport resistant cells have already been developed and are in clinical trial.

Glucose intolerance during decreased physical activity in man

Impaired glucose tolerance is a well documented consequence of absolute bedrest in man. Previous studies have shown a decrease in forearm glucose uptake during intravenous glucose infusion after fourteen days of bedrest. Bedrest is associated not only with physical inactivity but with a change in gravitational vector. This study was designed to examine the individual contributions of these factors to the glucose intolerance of bedrest. Thus, glucose tolerance tests were carried out in exercising subjects at bedrest and in rhesus monkeys immobilized in the vertical plane. Exercise in man improved glucose tolerance during bedrest, and vertically immobilized monkeys demonstrated significant glucose intolerance. It is concluded that the glucose intolerance of bedrest is a function of the decrease in physical activity.