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 Table of Contents  
Year : 2018  |  Volume : 13  |  Issue : 6  |  Page : 79-92

Oral Presentations

Date of Web Publication12-Dec-2018

Correspondence Address:
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-3698.247335

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How to cite this article:
. Oral Presentations. Indian J Rheumatol 2018;13, Suppl S2:79-92

How to cite this URL:
. Oral Presentations. Indian J Rheumatol [serial online] 2018 [cited 2019 Jun 16];13, Suppl S2:79-92. Available from:

  OPB0004: Dual inhibition by phosphodiesterase-5 and 5-HT2B inhibitors leads to near-complete amelioration of fibrotic potential of human dermal fibroblasts isolated from scleroderma patients Top

Saurabh Chaturvedi, Harshit Singh, Mohit Kumar Rai, Kritika Singh, Durga Prasanna Misra, Narayan Prasad1, Vinita Agrawal2, Vikas Agarwal; Departments of Clinical Immunology, 1Nephrology and 2Pathology, SGPGIMS, Lucknow, Uttar Pradesh, India

Background: Conversion of quiescent resident fibroblasts to activated myofibroblasts (MFBs) by transforming growth factor-β1 (TGF-β1) is the hallmark of fibrotic pathogenesis of systemic sclerosis (SSc). MFBs are characterized by increased α-smooth muscle actin (α-SMA) expression and extracellular matrix protein production.

Objective: The objective was to evaluate the antifibrotic potential of dual inhibition by phosphodiesterase-5 (PDE5) inhibitors, sildenafil and zaprinast, plus 5-HT2B inhibitor, SB204741, in human dermal fibroblasts (HDFs) isolated from the mid forearm skin of scleroderma patients.

Methods: In disease-mimicking strategy, HDFs were incubated with TGF-β1 (10 ng/ml)/ for 1 h, followed by TGF-β1 (10 ng/ml)/(sildenafil [10 μM] plus SB204741 [1 μM] or zaprinast [10 μM] plus SB204741 [1 μM]) for 24 h. In pretreatment strategy, HDFs were pretreated with sildenafil (10 μM) plus SB204741 (1 μM) or zaprinast (10 μM) plus SB20474 (1 μM) for 1 h and later with only TG F-β1 (10 ng/ml) for 24 h. Real-time-quantitative polymerase chain reaction for pro-fibrotic (COL1A1, COL1A2, ACTA2, CTGF, and FN1) and anti-fibrotic genes (MMP2/TIMP1) was performed. Immunoblotting was performed for α-SMA.

Results: In TGF-β1-stimulated HDF, upregulated expression of pro-fibrotic genes was observed (P < 0.05). The expression of pro-fibrotic genes in HDF cells stimulated with TGF-β1 was significantly (P < 0.05) reduced by dual-inhibition strategy with near-complete amelioration of ACTA2 in comparison to their respective individual treatments. Ratio of anti-fibrotic genes (MMP2/TIMP1) was restored significantly (P < 0.05). In TGF-β1-stimulated HDF, dual-inhibition strategy decreased the expression of α-SMA protein significantly (P < 0.05).

Conclusion: Dual-inhibition strategy with inhibitors of PDE5 plus 5-HT2B receptors leads to near-complete amelioration of conversion of fibroblasts to MFBs and thus may have the potential to treat fibrosis in scleroderma.

  OPB0006: IL-6 and IL-17 mediated hyper-induction mechanism of inflammatory chemokines exist in fibroblast like synoviocytes of reactive arthritis patients Top

Ramnath Misra, Sandeep Kumar, Rajeev Singh1, Abhishek Kumar Singh2, Daisuke Kamimura2, Sanjukta Majumdar, Mohit Rai, Yasunobu Arima2, Toru Atsumi2, Ratnadeep Mukherjee3, B Ravindran3, Vikas Agarwal, Masaaki Murakami2; Department of Clinical Immunology, SGPGIMS, Lucknow, Uttar Pradesh, 1ICMR-RMRC, Gorakhpur, Haryana, 2Molecular Psychoimmunology, Institute for Genetic Medicine, Hokkaido University, Japan, 3Institute of Life Sciences, Bhubneshwer, Odisha, India

Background/Purpose: Interleukin (IL)-17A- and IL-6-mediated hyperinduction of chemokines via nuclear factor-κB (NF) signaling (inflammation amplifier [Inf-amp]) is the main cause of spontaneous development of arthritis in F759 mice, which is having a substitution mutation in signal transducer subunit of IL-6 receptor gp130 (Y759F). Since higher level of IL-6 and IL-17 has been reported in synovial fluid (SF) of reactive arthritis (ReA) patients, we hypothesized that Inf-amp might be operational in these patients.

Methods: A total of twenty patients each with ReA and rheumatoid arthritis and ten patients with osteoarthritis (OA) were recruited in the study. Synovial fibroblasts (FLS) were isolated from SF of ReA patients and activated with IL-6, IL-17, and IL-6 plus IL-17, and the synergistic activation of IL-6 was measured. Moreover, effector chemokines, cytokines, and growth factors of Inf-amp were also measured in serum and SF of patients by luminex bead-based multiplex assay. The expression of these chemokines, cytokines, and growth factors was also checked by real-time-polymerase chain reaction (RT-PCR). In addition, the activation of NF-κB, STAT-3, and CREB was also measured in FLS by Western blotting.

Results: The synergistic activation of FLS with IL-6 and IL-17 produced more IL-6 [Figure 1] and has higher activation of NF-κB, STAT-3, and CREB in ReA patients. Moreover, levels of mediators of Inf-amp such as CCL-20, placental growth factor (PLGF), IL-6, and fibroblast growth factor (FGF)-basic were significantly higher in SF of ReA patients than OA patients. Similarly, RT-PCR results also showed that the expression of PLGF, IL-6, and epiregulin was significantly higher after the synergistic activation of FLS with IL-6 and IL-17. Levels of IL-6, Lcn-2, CCL20, PLGF, FGF-basic, and tenascin-C were significantly high, while levels of GRO-beta and CXCL-5 were significantly low in SF than serum in ReA patients.
Figure 1: FLS from reactive arthritis patients were activated with interleukin-6 and interleukin-17, and concentration of interleukin-6 was measured in culture supernatant

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Conclusions: These results suggest that IL-6- and IL-17-mediated Inf-amp is playing a major role in the pathogenesis of ReA.

  OPB0007: Interleukin-22 and Th22 cells in peripheral blood and synovial fluid of patients with enthesitis-related arthritis Top

Ankita Singh, Sandeep Kansurkar, Ramnath Misra, Amita Aggarwal; Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Introduction: In mouse model, enthesitis has been linked to interleukin (IL-22). Thus, we measured serum and synovial fluid (SF) IL-22 levels and IL-22-producing T-cells and correlated them with enthesitis and disease activity in children with enthesitis-related arthritis (ERA).

Methods: Children with ERA, polyarticular juvenile idiopathic arthritis (JIA), and healthy volunteers were studied. Disease activity in ERA was measured by the Juvenile Spondyloarthritis Disease Activity (JSpADA) Index. Th1, Th17, and Th22 cell frequency in blood (peripheral blood [PB]) and SF was measured by flow cytometry. Serum and SF IL-22 levels were measured by enzyme-linked immunosorbent assay.

Results: T-cell phenotype was assessed in forty children with ERA (33 boys), eight with polyarticular JIA and six healthy controls. The mean age was 15.73 ± 3.05, 13.62 ± 4.63, and 18 years, respectively. Twenty-seven patients (59.5%) had enthesitis and the mean JSpADA score was 3.83 ± 1.64. The frequency of Th1, Th17, and Th22 cells in PB was similar between the three groups. In paired samples, the median frequency of all the three T-cells was higher in SF, but only Th1 cells reached statistical significance (P < 0.02). The frequency of Th22 cells in PB was higher in children with active disease (JSpADA >2.5) as compared to children with minimally active/inactive disease (JSpADA <2.5; P < 0.02). It had no association with the presence of enthesitis. IL-22 level was measured in the sera of 85 children with ERA (78 boys), 14 children with polyarticular JIA (6 boys), and 31 healthy controls (27 boys). The mean age was 15.22 ± 3.17, 14.35 ± 6.34, 26.26 ± 8.11 years, respectively. There was no significant difference in IL-22 levels in the three groups. The SF IL-22 levels were higher than serum levels (175.8 pg/ml vs. 53.9 pg/ml; P < 0.05).

Conclusion: Higher PB Th22 cell frequency in patients with active disease and higher SF levels as compared to serum suggest that IL-22 contributes to inflammation; however, lack of association with enthesitis suggests that entheseal-site immune abnormalities may not be reflected in PB or even SF.

  OPB0008: Methylamine, a novel metabolite, may be a potential biomarker and player in the pathogenesis of scleroderma Top

Mohit Kumar Rai, Sakir Ahmed, Durgesh Dubey1, Atul Rawat1, Durga P Misra, Dinesh Kumar1, Vikas Agarwal; Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, 1Centre of Biomedical Research, Lucknow, Uttar Pradesh, India

Background/Purpose: Proton-based nuclear magnetic resonance (1H NMR) can identify the concentration of hundreds of small molecules in body fluids. A hypothesis-free approach was used to analyze metabolic perturbations in the sera of systemic sclerosis (SSc) to identify potential biomarkers of the disease.

Methods: Sera from 87 patients meeting ACR 1980 criteria for SSc and forty age- and sex-matched controls were analyzed using 1H NMR spectroscopy coupled with multivariate statistical analysis.

Results: There was a clear distinction between SSc and healthy controls on partial least square-discriminate analysis (R2 = 0.98). Several metabolites of discriminatory relevance were identified and further evaluated using analysis of variance and receiver operator curve analysis. Methylamine, nitrosodimethylamine (NDMA), citrate, and malonate were the four metabolites that had the maximum area under curve (>0.95) in distinguishing SSc from controls. Methylamine and NDMA were uniformly elevated almost exclusively in SSc patients. Additionally, methylamine could induce apoptosis in endothelial and fibroblast cells in a dose-dependent manner. Methylamine significantly potentiated fibroblasts isolated from SSc patients to express pro-fibrotic genes in a dose-dependent manner. However, treatment with tadalafil could significantly reduce the methylamine-induced profibrotic gene expression.

Conclusion: Methylamine and NDMA may be potential biomarkers. Methylamine by virtue of inducing endothelial cell apoptosis as well as profibrotic gene expression in fibroblasts has the potential to be the major player in the pathogenesis of SSc. Tadalafil has the potential to reduce fibrosis in SSc by decreasing methylamine-induced profibrotic gene expressions.

  OPB0013: Targeted 1H nuclear magnetic resonance-based metabolomics analysis revealed significantly higher synovial phenylalanine-to-tyrosine ratio in reactive arthritis and undifferentiated spondyloarthropathy Top

Hafis Muhammed, Dinesh Kumar1, Durgesh Dubey1, Sandeep Kumar, Smriti Chaurasia, Anupam Guleria1, Sanjukta Majumdar, Rajeev Singh2, Vikas Agarwal, Ramnath Misra; Department of Clinical Immunology, SGPGIMS, 1Centre of Biomedical Research, SGPGIMS, Lucknow, Uttar Pradesh, 2ICMR-RMRC, Gorakhpur, Haryana, India

Background and Hypothesis: Elevated phenylalanine-to-tyrosine ratio (Phe/Tyr) in serum of patients having sepsis and infection with HIV-1 and hepatitis C virus has been described. We postulate that this ratio is worth exploring in serum and synovial fluid (SF) of patients with reactive arthritis (ReA)/undifferentiated spondyloarthropathy (uSpA), as there is an infectious trigger to this condition.

Objective: The objective of this study was to analyze synovial Phe/Tyr ratio in serum and SF of patients with ReA/uSpA and compare them with rheumatoid arthritis (RA) and osteoarthritis (OA) by nuclear magnetic resonance (NMR) spectroscopy.

Methods: Paired SF and serum of thirty patients with ReA/uSpA (24 males, with a mean age of 27.96 years), 25 patients with RA fulfilling ACR classification criteria (20 females, with a mean age of 41.5 years), and 21 patients with OA (16 females, with a mean age of 59.8 years) were collected and analyzed using a one-dimensional 1H CPMG NMR spectra recorded on 800 MHz NMR spectrometer equipped with a TCI CryoProbe™ (at 300 k). Phenylalanine and tyrosine were quantified.

Results: Synovial Phe/Tyr ratio was significantly higher in ReA/uSpA (mean value = 22.08 ± 10.18) compared to RA (mean value = 1.26 ± 0.20; P < 0.001) and OA (mean value = 1.18 ± 0.31; P < 0.001). Synovial Phe/Tyr ratios were comparable in RA and OA patients with P = 0.257. Compared to serum, the Phe/Tyr ratios were significantly (P < 0.001) higher in the SF in ReA/uSpA. The Phe/Tyr ratios were also found to be positively correlated between serum and SF samples with regression coefficient (r2) of 0.2873 [Figure 1].
Figure 1: (a) The synovial phenylalanine/tyrosine ratio compared between reactive arthritis, rheumatoid arthritis, and osteoarthritis patients using unpaired t-test. (b) The synovial phenylalanine/tyrosine ratio compared between reactive arthritis and osteoarthritis patients. (c) The phenylalanine/tyrosine ratios compared between paired synovial fluid and serum samples of reactive arthritis patients using paired t-test. (d) The correlation plot between phenylalanine/tyrosine ratios obtained for paired synovial and serum samples of reactive arthritis patients

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Conclusions: NMR-based metabolomics study demonstrates that the synovial profiling of Phe/Tyr ratio is specifically elevated in ReA/uSpA.

  OPB0010: NMR spectroscopy reveals alterations of urinary acetate and citrate levels following Cyclophosphamide therapy in patients with Lupus nephritis Top

Ganguly S, Kumar U, Gupta N, Guleria A, Majumdar S, Phatak S, Chaurasia S, Kumar S, Aggarwal A, Kumar D, and Misra R; SGPGI Lucknow, CBMR Lucknow, Uttar Pradesh, India

Aim: Metabolomics, the study of global alterations in small metabolites, is a useful tool to look for novel biomarkers. Recently, we reported a reprogramming of the serum metabolomic profile on nuclear magnetic resonance (NMR) spectroscopy following treatment in lupus nephritis (LN).[1]

Objective: We explored urinary parameters using NMR spectroscopy in patients with biopsy-proven proliferative LN. Change in parameters after 6-month cyclophosphamide induction treatment and its correlation with disease activity were assessed.

Methods: Urine obtained from LN patients (n = 18, females = 16, males = 2) at diagnosis and following induction therapy with cyclophosphamide and healthy controls (HC) (n = 18, median age: 35 years, all males) was stored at −80°C. Metabolomic profiling was done using high-resolution 800 MHz one-dimensional 1H NMR spectroscopy. Urinary ratio of metabolites was calculated as follows: (metabolite × 1000)/creatinine. Disease activity was measured using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Metabolomic profiles were compared between groups and correlated with clinical parameters using SPSS software.

Results: Urinary metabolomic fingerprint of LN patients differed from that of HCs by having significantly raised urinary acetate/creatinine (LN = 41.84 ± 100.6, HC = 12.36 ± 9.40, P ≤ 0.002) and reduced urinary citrate/creatinine (LN = 34.22 ± 54.8, HC = 114.5 ± 70.09, P ≤ 0.0001). Urinary citrate (88.68 ± 98.33) increased after 6 months of cyclophosphamide, while urinary acetate showed a trend toward decrease (14.77 ± 9.98). Area under curve for urinary citrate/creatinine and acetate/creatinine was 0.9136 and 0.8086, respectively. The urinary acetate levels correlated with SLEDAI (r = 0.337, P = 0.048). Urinary citrate levels correlated with C3 (r = 0.362, P = 0.03) and negatively correlated with urinary protein-to-creatinine ratio (r = 0.346, P = 0.039).

Conclusions: The decreased urinary citrate mirrors the finding seen in serum of the patients done earlier, which reflects dampened aerobic glycolysis and oxidative phosphorylation.[1] Raised urinary acetate levels possibly reflect renal tubular injury and decreased entry into the tricarboxylic acid cycle. Urinary metabolomics parameters are potential noninvasive biomarkers for diagnosis and monitoring treatment response in LN.


  1. Guleria A, Phatak S, Dubey D, Kumar S, Zanwar A, Chaurasia S, et al. NMR-based serum metabolomics reveals reprogramming of lipid dysregulation following cyclophosphamide-based induction therapy in lupus nephritis. J Proteome Res 2018;17:2440-8.

  OPB0019: Differential expression of different regulatory RNA molecules (long noncoding RNAs) in patients with systemic sclerosis Top

Dipanjan Bhattacharjee, Sudipta Chatterjee, Nitai P Bhattacharyya1, Sanchaita Misra, Alakendu Ghosh; Department of Rheumatology, Institute of Post Graduate Medical Education and Research, SSKM Hospital, 1Biomedical Genomics Centre, Kolkata, West Bengal, India

Background: Tumor suppressor lncR (MEG3), pro-metastatic lncR (MALAT1), and transcription-regulating lncR (NEAT1) have been implicated in different forms of cancer. Recent studies have suggested that NEAT1 regulates the transformation of epithelial cells to mesenchymal cells in hepatic carcinoma. Microvascular dysfunction is one of the major clinical challenges in systemic sclerosis (SSc). There are some studies that indicate endothelial-to-mesenchymal transformation of the major event for microvascular dysfunction.

Objective: The study objective lies in comparative quantification of the systemic expression of regulatory RNAs (lncRs) involved in regulating the microvascular dysfunction in patients with diffused cutaneous SSc (dSSc).

Methods: A total of 15 consecutive dSSc patients (ACR, 2013) and 10 age- and sex-matched healthy controls (HCs) were included in the study. Blood samples were collected from all the study participants, and peripheral blood mononuclear cells (PBMCs) were isolated. RNA was isolated from all the PBMC samples. cDNAs were prepared, and the relative expressions of NEAT1, MALAT1, and MEG3 were measured with respect to an endogenous control gene by real-time-polymerase chain reaction.

Results: The expression levels of MEG3, MALAT1, and NEAT1 in PBMCs were significantly higher (P < 0.0001, P = 0.002, and P < 0.0001, respectively) in patients with scleroderma with respect to HCs. The mutual expressions of the lncRs could be compared as follows: NEAT1>MALAT1>MEG3 in scleroderma (P < 0.0001). The patients with disease duration >5 years had statistically significant (P < 0.0001) higher expression of NEAT1 compared to those with disease duration.

Conclusion: Increased expression of MEG3, MALAT1, and NEAT1 in the patient group suggests the functional involvement of lncRNAs in the disease pathogenesis. Increased expression of NEAT1 in the patient group with longer disease duration indicates more specific functional involvement of the lncRNA in SSc.

  OPB0021: Skewing of T-helper axis toward Th1, Th2, and Th17 cells in sarcoid arthritis compared to nonarticular sarcoidosis Top

Harshit Singh, Avinash Jain, Saurabh Chaturvedi, Sanat Phatak, Sajal Ajmani, Alok Nath1, Durga P Misra, Vikas Agarwal; Departments of Clinical Immunology and 1Pulmonary Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India

Introduction: Sarcoidosis is a disease with diverse manifestations and an unclear pathogenesis. An insight into the T-cell signature may help us understand the disease phenotype better.

Objective: The objective of this study was to assess T-cell subsets in sarcoidosis patients with or without articular involvement.

Methods: Treatment-naïve patients of sarcoidosis proven by tissue diagnosis and negative for acid-fast Bacilli, fungal elements, and/or Lofgren syndrome with negative Mantoux test were divided into two groups – Group A (articular involvement)/Group B (without articular involvement). T-cell immunophenotyping was done in peripheral blood by flow cytometry for Th1, Th2, Th17, and Treg cells. Interleukin (IL)4, IL10, interferon (IFN)-gamma, and IL17 were measured in culture supernatant and serum using enzyme-linked immunosorbent assay.

Results: A total of 29 patients in Group A were compared with 18 patients in Group B (9 with pulmonary involvement, 4 renal, 1 gastrointestinal, and 4 others), with mean age of 39.9 ± 10.2 years and 43.2 ± 11.8 years and male - 9 and 11, respectively. Median total leukocyte count and absolute lymphocyte count were comparable in both groups (8350 cells/mm3 [7195–9035]) and 2141 cells/mm3 [1824–2588] in Group A versus 7400 cells/mm3 [6000–8960] and 2220 cells/mm3 [1748–2350] in Group B, respectively, P > 0.05). CD4/CD8 ratio was altered but similar in both the groups (Group A, 0.96 [interquartile range (IQR): 25–75 0.9–1.2]/Group B, 1.1 [IQR: 25–75 0.98–1.2]). Median Th1, Treg, IFN–gamma, and IL10 were higher in Group B (69.1% [65.8–70.8], 12.05% [9.9–15.6], 588.2 pg/ml [436.7–825.2]/119.8 pg/ml [107.8–144.3]) respectively compared to Group A (49.7% [48.3–52.6], 2.99% [2.6–3.6], 243.2 pg/ml [144.7–297.7]/48.8 pg/ml [41–57.3]), respectively, and Th2 and IL4 were higher in Group A 42.7% (41–45)/121 pg/ml (106.7–142.8)/17.1% (15–18.7)/28.1 pg/ml (21–36.3) in Group B respectively. However, higher Th1/Treg, Th2/Treg, and Th17/Treg meant skewing of axis toward Th1, Th2, and Th17 in articular sarcoidosis [P < 0.0001; [Figure 1]].
Figure 1: Flow cytometry analysis of T-cell subset ratio in peripheral blood in articular and nonarticular groups. Higher Th1/Treg, Th2/Treg, and Th17/Treg in articular group meant skewing of axis to Th1, Th2, and Th17 axes. Ratios are expressed as median with interquartile range25-75. Th1/TregA, Th2/TregA, and Th17/TregA refer to the ratio in articular group A and Th1/TregB, Th2/TregB, and Th17/TregB in nonarticular group B. ****: P < 0.0001

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Conclusion: Difference in T-cell subsets may explain to an extent the diversity in the disease manifestations and may have implications on management.

  OPB0028: NMR based serum metabolomics revealed distinctive metabolic Patterns of ANCA-associated vasculitis compared to TAKAYASU Arteritis and Systemic lupus erythematosus Top

Gayatri G Ekbote, Dinesh Kumar1, Latika Gupta2, Avinash Jain2, Umesh Kumar1, Ritu Raj1, Anupam Guleria1, Vikas Agarwal2, Rajiva Gupta, Ramnath Misra2; Medanta-The Medicity, Sector-38, Gurgaon, Haryana, 1Centre of Biomedical Research, 2Department of Clinical Immunology, SGPGIMS, Raibareli Road, Lucknow, Uttar Pradesh, India

Background and Objective: Metabolomics, a hypothesis-free approach, has contributed to the comprehension of multiple autoimmune diseases. Distinctive metabolic signatures shed some light on the underlying pathogenesis. Takayasu arteritis (TA) predominantly affects large vessel, whereas systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV) can affect small and medium vessels. We hypothesize that the serum metabolic profiles of AAV patients are different when compared to TA and SLE patients.

Methods: Serum samples from 54 AAV, 98 TA, and 49 SLE patients and 77 healthy controls were collected for metabolomics analysis. The serum metabolic profiles were measured using one-dimensional 1H-CPMG nuclear magnetic resonance (NMR) experiments using high-resolution 800 MHz NMR spectrometer and compared using multivariate partial least-squares discriminant analysis [PLS-DA, [Figure 1]a]. The discriminatory metabolites were identified based on variable importance in projection statistics and further evaluated for statistical significance (P < 0.05). To access the degree of metabolic perturbation and phenotyping discrimination, we also performed the random forest (RF) analysis [Figure 1]b.
Figure 1: (a) Partial least-squares discriminant analysis and (b) random forest analysis of one-dimensional 1H CPMG nuclear magnetic resonance spectra of serum samples obtained from AAV, TA, and SLE patients. The random forest analysis in (b) also involves normal control group for which the error is coinciding with the overall error rate (in redline). The different colors represent different study groups as labeled along with their demographic characteristics in the inset table. AAV: Antibody-associated vasculitis, TA: Takayasu arteritis, SLE: Systemic lupus erythematosus

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Results: An exquisite separation in the two-dimensional score plot of PLS-DA between AAV (n = 54, mean age: 46.5 years), TA (n = 98, mean age: 27 years), and SLE (n = 49, mean age: 33 years) patients clearly revealed that the metabolic disturbances associated with AAV are specific and different to TA and SLE [Figure 1]a. Sera of AAV patients were characterized by increased serum levels of N-acetyl-glycoproteins, lipid/membrane metabolites including low/very low-density lipoproteins, polyunsaturated fatty acids, choline, and glycerophosphocholine, whereas, serum levels of glucose and various amino acids (including glutamate, histidine, valine, leucine, and isoleucine) were found to be decreased significantly compared with both TA and SLE. RF classification analysis revealed that serum metabolic perturbations in AAV significantly differed from SLE with respect to TA [Figure 1]b.

Conclusion: Significant metabolic differences were found between AAV, TA, and SLE patients, suggesting different underlying pathophysiologies of these diseases.

  OPB0025: Utility of soluble triggering receptor expressed on myeloid cells type-1 and procalcitonin to differentiate bacterial infection from disease flare in systemic lupus erythematosus and antineutrophil cytoplasmic antibody-associated vasculitis Top

Mantabya Singh, Harshit Singh, Saurabh Chaturvedi, Sajal Ajmani, Vikas Agarwal; Department of Clinical Immunology, SGPGIMS, Lucknow, Uttar Pradesh, India

Background: Differentiation between a flare of a rheumatic disease and systemic infection in a patient receiving immunosuppressive treatment is vitally important as the treatment differs dramatically. However, in routine clinical practice, this remains a common dilemma since many patients present with signs and symptoms of nonspecific inflammation such as fever, arthralgia, and shortness of breath that can be caused by both disease activity and infection. Soluble triggering receptor expressed on myeloid cells type 1 (sTREM-1) and procalcitonin are evaluated for the selection of infection.

Objective: The study objective was to evaluate sTREM-1 in serum to differentiate between systemic infection and active autoimmune inflammation in patients with systemic lupus erythematosus (SLE) and antineutrophil cytoplasmic antibody-associated vasculitis (AAV).

Methods: A total of 76 patients and 20 healthy controls were included in the study. Patients were divided into three groups as follows – active disease, proven infection, and probable infection. sTREM-1 and procalcitonin levels were measured in duplicate after a single freeze-thaw cycle in batched assays by sandwich enzyme-linked immunosorbent assay as per manufacturer's protocol.

Results: Total leukocyte count, erythrocyte sedimentation rate, C-reactive protein, C3, C4, and anti-dsDNA in SLE and titers of anti-MPO and anti-PR3 in antineutrophil cytoplasmic antibody-associated vasculitis were not significantly different in patients with active disease and infection. Mean (range) sTREM-1 was higher in both patients with active disease (1184 [717–1609] pg/ml) and infection (899 [531–1284] pg/ml) in comparison to healthy controls (255.1 [95.1–634.8] pg/ml). Procalcitonin was higher in patients with infection compared to those with active disease. Procalcitonin value of 244 pg/ml had a sensitivity of 75% and a specificity of 85% to differentiate infection from active disease with an area under the curve of 0.75. The positive and negative predictive values were 70.4% and 87.8%, respectively.

Conclusion: Compared to sTREM-1, procalcitonin is better in differentiating infection from disease activity in patients with SLE and AAV.

  OB0004: Plasmacytoid Dendritic Cells Contribute to Systemic Sclerosis Top

Isela Valera, Suzanne Kafaja, Anagha A. Divekar, Rajan Saggar, Fereidoun Abtin, Dinesh Khanna, Daniel E. Furst, Ram Raj Singh; David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA

In patients with systemic sclerosis (SSc), plasmacytoid dendritic cells (pDCs) are reduced in the peripheral blood, but increase in lungs and skin (Kafaja S….Singh RR, J Clin Invest Insight 2018). Similar results were obtained in the bleomycin-induced model of SSc. Importantly, depletion of pDCs ameliorated bleomycin-induced SSc and altered the expression levels of proteins and genes implicated in chemotaxis/inflammation/fibrosis in the lungs. In resonance with animal findings, the frequency of pDCs in the lungs of patients with SSc correlated with the severity of lung disease. Treatment with a tyrosine kinase inhibitor imatinib that reduces and/or prevents deterioration of fibrosis reduced pDCs in lungs but not in peripheral blood of SSc patients. In SSc patients, the frequency of pDCs also correlated with the levels of proteins implicated in inflammation/vasculopathy/fibrosis.

To test if pDCs directly contribute to inflammatory/profibrotic milieu in scleroderma, we injected C57Bl/6 mice with bleomycin, harvested lungs, and analyzed lung extracts for proteins by Western blot, enzyme-linked immunosorbent assay, and multiparametric flow cytometry.

Scavenger receptor CD36 that is implicated in platelet–collagen adhesion, oxidative stress, and inflammation was increased on pDCs but not on myeloid dendritic cells (mDCs), other myeloid cells, B-cells, and T-cells in the lungs of bleomycin-injected animals as compared to control animals. TLR7 was also increased more on pDCs than on all other immune cells examined, whereas TLR2 was increased more on mDCs and other myeloid cells but not on pDCs and B-cells. Transforming growth factor β-latent peptide was higher on all immune cells examined in the lungs.

In summary, pDCs elicit pro-inflammatory/pro-fibrotic milieu in the development of systemic fibrosis. These observations along with recent reports identify the increased trafficking of pDCs to the affected organs as a therapeutic target in SSc.

  OPB0023: Metformin reduces P-glycoprotein expression on peripheral blood mononuclear cells and potentiates the action of corticosteroids in systemic lupus erythematosus Top

Sandeep Kansurkar, Mohit K Rai, Durga P Misra, Vikas Agarwal; Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Introduction: Metformin activates activated protein kinase and alters the transcription of multiple cytokines. We studied the effect of metformin on the secretion of cytokines interleukin-1 beta (IL-1β), interferon gamma (IFN-γ), tumor necrosis factor-α, IL-6, IL-10, and transforming growth factor-β (TGF-β) by peripheral blood mononuclear cells (PBMCs), which are key effector cells in lupus. P-glycoprotein (P-gp) expression is linked to drug resistance and has been shown to be associated with higher disease activity in lupus. Metformin inhibits the expression of P-gp in cancer cells. There is sparse data on the effect of metformin on P-gp expression and its impact on cytokine secretion by PBMC in lupus.

Methods: PBMCs of nine lupus patients (mean age: 30 years, all females) were stimulated with phorbol myristate acetate (PMA)/ionomycin, with or without increasing the dose of metformin (0.01, 0.1, 1, and 10 mM/L) for 24 h. Cytokines IL-1β, IL-6, IFN-γ, and IL-10 were analyzed by enzyme-linked immunosorbent assay in culture supernatant. Cell viability with metformin was assessed by MTT assay. P-gp expression on PBMC was measured by flow cytometry. In another experiment, PBMCs from four patients were cultured with metformin (0.1 mM), prednisolone (0.3 μM), and a combination of metformin (0.1 mM) + prednisolone (0.3 μM), and the concentrations of IL-1, IFN-γ, and IL-10 were measured in culture supernatant.

Results: Metformin decreased the expression of P-gp in PBMC in a dose-dependent manner (P = 0.003). In the PBMC cultures with PMA/ionomycin and metformin, there was dose-dependent decrease in the concentration of IL-1β (P = 0.001), IL-6 (P = 0.007), and IFN-γ (P < 0.001) and increase in that of IL-10 (P = 0.014) and TGF-β (P = 0.005) at all concentrations of metformin. PBMC culture with a combination of metformin and prednisolone had lower concentration of IL-1β and IFN-γ and higher concentration of IL-10 than with prednisolone or metformin alone.

Conclusion: Metformin reduces P-gp expression, decreases pro-inflammatory cytokines, increases anti-inflammatory cytokines, and potentiates the effect of corticosteroids.

  OPC0019: Randomized controlled trial to compare the efficacy of initial combination therapy of sildenafil and bosentan versus sildenafil alone for pulmonary arterial hypertension in systemic sclerosis Top

Preksha Dwivedi, Shefali K Sharma, Varun Dhir, M B Adarsh, Rohit Manoj1, D Behera2, Sanjay Jain; Departments of Internal Medicine, 1Cardiology and 2Pulmonary Medicine, PGIMER, Chandigarh, India

Background: Systemic sclerosis (SSc)-associated pulmonary arterial hypertension (PAH) is one of the leading causes of death. Data on the effects of PAH-specific therapy in SSc are scarce.

Objective: The objective was to study the efficacy and safety of monotherapy (sildenafil) versus initial combination therapy (sildenafil and bosentan) for the treatment of SSc-related PAH.

Methods: In this 24-week, single-center, double-blind, placebo-controlled trial, 34 symptomatic (NYHA Functional Class II/III) treatment-naïve patients of SSc-PAH (pulmonary artery systolic pressures [PASP] >35 mmHg) with forced vital capacity >60% were randomized at 1:1 ratio to the combination of sildenafil and bosentan (62.5 mg increase to dose 125 mg twice daily) or sildenafil (20 mg thrice daily) monotherapy. The primary and secondary outcomes were to assess the change in PASP and to compare the change in 6 m walk distance (6MWD), time to clinical worsening (TTCW), and adverse event. Intention-to-treat analysis was carried out for the primary and secondary outcomes. Kaplan–Meier survival analysis was done to estimate the time to PAH worsening.

Results: Mean change in PASP in the monotherapy arm was −1.0 mmHg versus +2.1 mmHg in combination arm (P = 0.56). TTCW was prolonged in the combination arm. The mean survival time in the combination group and monotherapy group was 23.76 ± 0.59 weeks and 23.28 ± 0.23 weeks, respectively. The hazard ratio is 0.73 (95% confidence interval 0.04–11.7) (P = 0.872). The mean change in the 6MWD in the monotherapy arm and combination arm was 15.88 ± 31.83 m and 25.88 ± 38.25 m (P = 0.38), respectively. The rates of adverse events were similar in both groups.

Conclusion: We could not demonstrate the efficacy of initial combination therapy over sildenafil monotherapy. Patients tolerated the initial combination well and early treatment prevented further deterioration.

  OPC0052: Serum Fatty Acid Binding Protein 3 (FABP3) levels differentiate active from inactive myositis and correlate with response to therapy Top

Latika Gupta, Sanjukta Majumdar, Amita Aggarwal, Ramnath Misra, Able Lawrence; Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Background: Idiopathic inflammatory myositis results in significant morbidity, and often mortality. While delayed diagnosis leads to wasted muscles, conventional markers fail to differentiate the reversible component of subclinical inflammation among prevalent damage. Fatty acid-binding protein 3 (FABP3) is a small cytosolic protein involved in fatty acid transport that is preferentially expressed in slow-twitch skeletal muscle fibers. Its selective expression makes it a suitable candidate biomarker to differentiate leaky diseased muscles from those with damage.

Methods: Patients with inflammatory myositis seen between December 2017 and August 2018 were recruited for the study. Those with active infection, pregnancy, renal dysfunction, or chronic kidney disease were excluded from the study. Apart from patient and disease variables, activity and damage were assessed using standard IMACS core set measures. Sera were collected at the first visit and in those with active disease follow-up samples were collected at 6 months. Those with Myositis Disease Activity Assessment Tool activity score ≥1 were scored as active disease. FABP3 was estimated in sera using enzyme-linked immunosorbent assay. Nonparametric tests were used for paired and unpaired analyses.

Results: A total of 132 myositis (12 juvenile dermatomyositis, 55 dermatomyositis, 19 polymyositis, 21 overlap, and 24 antisynthetase syndrome) patients (33 men and 99 women) with a median age of 38 (24.5–46.0) years and disease duration of 0.9 (2.3–5.1) years were included in the study. Mean FABP3 values were higher in those with active (5.73 ng/ml) as compared with inactive (2.92 ng/ml, P = 0.0351) disease. Of the nine cases followed up for 6 months, levels (figure) fell with treatment in treatment responders (n = 7, 14.5–7.5 ng/dl, P = 0.03). FABP3 did not differ between those with different types of myositis or a history of polycyclic versus monocyclic course.

Conclusion: Serum FABP3 may be a useful marker of disease activity and response to therapy in inflammatory myositis.

  OPC0063: Lymphocyturia is a good and cheap biomarker for lupus nephritis Top

Sarit Sekhar Pattanaik, Ankita Singh, Shilpa Venkataraman1, Ramnath Misra, Amita Aggarwal; Departments of Clinical Immunology and 1Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Introduction: Multiple urinary biomarkers are being described for lupus nephritis (LN); however, none has reached the clinic. Hematuria and leukocyturia are the traditional markers of nephritis, but leukocyturia can occur due to infection. Recently, urinary CD4 and CD8 T-cells have shown high specificity for LN. Thus, we studied whether urinary lymphocytes by simple staining method or FACS can serve as cheap and effective biomarker.

Methods: Patients with active LN (ALN), inactive nephritis (IN), and active lupus without nephritis (ANR) were included in the study. Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was calculated. Renal biopsy was done if not contraindicated. Lymphocytes in the urine were stained using Kovak stain. CD3 T-cells were counted by FACS using anti-CD3 antibody and DAPI.

Results: Among 38 patients with ALN (35 females, mean age – 30.2 years and SLEDAI – 12.8 ± 6.98). Ten patients of ANR (9 females, mean age – 27, SLEDAI – 7.88 ± 4.49) and 8 patients of IN (all females, mean age – 31.8, SLEDAI – 0.6 ± 0.89). The mean lymphocyte count per high-power field was 20.7 ± 86.7 in ALN as compared to ANR (2.7 ± 1.5, P = 0.68) and IN (2.4 ± 3.8, P = 0.58). The mean CD3 count per ml was 6.6 ± 11 in ALN as compared to ANR (2.7 ± 3, P = 0.72) and IN (2 ± 3.51, P = 0.104). There was a good correlation between lymphocyturia and urinary CD3 cells (r = 0.636, P < 0.001).

The lymphocyturia had good correlation with SLEDAI (r = 0.495, P = 0.001) and rSLEDAI (r = 0.427, P = 0.007). Similarly, the urinary T-cell had good correlation with SLEDAI (r = 0.381, P = 0.004) and rSLEDAI (r = 0.530, P < 0.001).

In 25 patients with renal biopsy, lymphocyturia had good correlation with activity index (r = 0.392, P = 0.03) but not with chronicity. The area under curve for differentiating ALN from IN was 0.758 for lymphocyturia and 0.851 for urinary T-cells.

Conclusion: Lymphocyturia measured by simple staining of urinary sediment can be a cheap and effective marker of ALN.

Acknowledgment: The study was supported by IRA research grant (2018) to SSP.

  OC0046: Comparison of Sulfasalazine versus Leflunomide based combination disease modifying anti rheumatic drug therapy (DMARD) in patients with Rheumatoid arthritis failing Methotrexate monotherapy: A randomized control trial Top

Pooja Belani; Senior Resident, Clinical Immunology, JIPMER, Puducherry, India

Background: Methotrexate (MTX) monotherapy-resistant rheumatoid arthritis (RA) can be treated with either combination of conventional synthetic disease-modifying antirheumatic drug therapy (csDMARDs) or biologic DMARD. High cost and increased risk of tuberculosis reactivation with biologics and an equivalent efficacy of combination DMARD therapy make the latter an inevitable next choice in developing countries like India. However, there is no consensus on the best combination csDMARD therapy due to lack of head-to-head trials comparing different combination therapies. Here, we studied the outcomes of two commonly used combination csDMARD regimens in RA.

Objective: The objective of this study was to compare the efficacy and safety of the two combination csDMARD therapy in RA patients failing MTX monotherapy.

Methods: This is a 12-week, open-label, randomized, parallel-group clinical trial. RA patients with disease <2 years failing MTX monotherapy were randomized to add either of the two treatment regimens – leflunomide + hydroxychloroquine or sulfasalazine + hydroxychloroquine. The primary endpoint was proportion of patients achieving European League Against Rheumatism (EULAR) good response. The secondary endpoints were improvement in iHAQ, US7 score, and adverse events.

Results: Out of the 805 patients screened, 256 eligible patients were included in the trial and started on MTX monotherapy. Among them, 118 patients (46%) responded and 136 nonresponders were randomized to leflunomide (LEF) or sulfasalazine (SSZ) group (two patients were excluded). At the end of 12 weeks, 58.8% and 54.4% patients achieved EULAR good response in each group, respectively (P = 0.7, odds ratio [OR]: 1.1, 95% confidence interval [CI]: [0.6–2.36]]. DAS 28 remission was achieved by 42.6% and 44% of patients and median iHAQ was 0.7 (interquartile range [IQR]: 0.4–1) and 0.5 (IQR: 0.07–1.3) (P = 0.9) in LEF and SSZ groups, respectively. The change in US7 score and adverse events was statistically similar in both the groups. More patients in SSZ group required parenteral MTX as compared to LEF group (21% vs. 7.5%) (P = 0.04, OR: 3.2, 95% CI: [1.1–9.6]).

Conclusion: Both the combination therapies are equally effective in MTX monotherapy-resistant RA with a comparable safety profile. However, combination of oral SSZ and MTX may have higher incidence of gastrointestinal intolerance requiring switch to parenteral MTX.

  OPC0201: Anti-fibrotic efficacy of phosphodiesterase-5 inhibitors in vitro and in-vivo in Systemic sclerosis patients Top

Sakir Ahmed, Mohit K Rai, Durga P Misra, Saurabh Chaturvedi, Harshit Singh, Vikas Agarwal; Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Background: Antifibrotic effects of phosphodiesterase-5 inhibitors (PD5i) was investigated in-vitro and in-vivo for systemic sclerosis (SSc) patients.

Methods: Skin fibroblasts were cultured from 5 healthy controls and 13 SSc patients. These were treated with three PD5i (tadalafil, sildenafil, zaprinast) both before and after stimulation with TGF-β1. Gene expression was studied by real-time PCR for mRNA (COL1A1, COL1A2, CTGF, ACTA2, TIMP1, and MMP2). Western blotting for proteins (Collagen-I, α-SMA) was carried out. Additionally, in 24 patients with SSc, 12 were randomized to receive routine care (control group), and rest received tadalafil in addition to routine care (control group) in a prospective open label design. Clinical details including mRSS and paired forearm skin biopsies of 5mm diameter were obtained at baseline and at 6-month. Expression of a 4-gene biomarker (COMP, THBS1, SIGLEC1, IFI44) and of pro-fibrotic genes (TN-C, COL1A1, COL1A2, ACTA2 and CTGF) in skin biopsies was analyzed using real-time PCR.

Results: Tadalafil significantly decreased profibrotic genes mRNA expression with increased anti-fibrotic gene mRNA expression in fibroblast cultures[Figure 1]. The other PD5i, sildenafil and zaprinast, showed similar effects as tadalafil but with smaller effect size. Western blots mirrored the changes. The patients had comparable baseline characteristics in both tadalafil and control groups. At six months: median mRSS decreased from 22 to 13 (P = 0.005) in patients receiving tadalafil and changed from 15 to 19 (P=1) in patients receiving only routine care. There was significant decrease in the expression of COMP, SIGLEC1, CTGF and IFI44 in the Tadalafil group with significant increase in the expression of IFI44, THBS1 and TN-C in the control group [Table 1]. Change in mRSS correlated with change in SIGLEC1, IFI44, TBHS1 and COL1A1 mRNA expressions.

Table 1: Changes in gene expression (as compared to Glyceraldehyde 3-phosphate dehydrogenase) from baseline to 6 months in skin biopsies

Click here to view

Conclusion: PD5i showed anti-fibrotic effect both in vitro fibroblast culture, and in-vivo in a six months long clinical study in SSc patients.

  OPC0161: Clinical experience of tofacitinib in rheumatoid arthritis over 24 weeks: Real-world data from two centers in South India Top

Vijay K R Rao, Ramakrishna Rao Uppuluri1, Challa Satyavati1, Challa Sripurna Deepti1, Challa Shivshankar1, Kumar Datta1, Jonnada Shivanand1, Younis Maryam1, Suryakari Archana Rani1, Arava Shashikala1; Divisha Arthritis and Medical Center, Bengaluru, Karnataka, 1Sri Deepti Rheumatology Centre, Hyderabad, Telangana, India

Background: Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). Published real-world data with tofacitinib use in Indian patients are limited.

Objectives: The objective was to evaluate the real-world efficacy and safety in patients not responding to conventional synthetic disease-modifying antirheumatic drug therapy (csDMARDs) or biological DMARDs (bDMARDs) in routine clinical practice.

Methods: Data of RA patients treated with tofacitinib 5 mg BID from two tertiary hospitals in South India were collected from October 2016 to July 2018 using standardized formats at baseline and 1, 3, and 6 months. Efficacy was evaluated by DAS28-4 (erythrocyte sedimentation rate [ESR]) and Visual Analog Scale for Physician Global Assessment, and safety was evaluated by listing of adverse events/serious adverse events (AEs/SAEs). Concomitant RA treatment type/dose adjustments were as per the clinician's discretion. Analysis was based on the observed values without imputation for missing data.

Results: Among a total of 87 patients, majority were females (n = 79; 90.8%); mean age/disease duration, mean (range), 50.6 (20–79) years 79) years, 9 (1–30) years 30) years, respectively; 84/87 patients were rheumatoid factor +/anti-citrullinated protein antibody +. Tofacitinib was given in post-csDMARD (only methotrexate [MTX]-inadequate responder [IR] [17 patients], double csDMARD-IR [22 patients], and triple csDMARD-IR [36 patients]) in 86% of patients and after ≥1 bDMARD (1bDMARD [9 patients], 2 bDMARD [2 patients], and 4 bDMARD [1 patient]) in 14% of patients. Used mostly combined with csDMARDs in 96.5% patients (mostly with MTX [45 patients]/or double csDMARD combination [39 patients]) and as monotherapy in 3.5%. Average MTX dose was 14.6 mg/week. Patients were at various stages of therapy. Disease activity before/after treatment is shown in Graph/Table 1. At 1, 3, and 6 months, the percentage of patients in DAS28-4 (ESR) remission/low disease activity was 8.3%/20.2%, 41.3%/55.1%, and 77.4%/83.8%, respectively. Sixteen AEs were noted as follows: upper respiratory tract infection (3), thrombocytopenia (2), elevated serum glutamate-pyruvate transaminase (2), neutropenia (1), herpes simplex (1), hypertriglyceridemia (1), herpes zoster (1), urinary tract infection (1), and skin infection (1). No cases of tuberculosis were noted. Most AEs were mild and reversible. Nearly 36% of patients discontinued – 20%, 8.5%, and 5% due to economic reasons, AEs, and inadequate response, respectively.

Conclusion: Patients with severe RA showed good EULAR response as early as 1 month and sustained through 6 months. No new safety signals were identified. Present real-world data are reassuring, but they need more experience among rheumatologists over longer duration.

  OC0037: Inflammatory Disease Activity and Vascular Inflammation improve with HMG-CoA reductase inhibition and Angiotensin Receptor Blockade in Rheumatoid Arthritis: RA- Statin/ARB Study Top

Ashit Syngle, Nidhi Garg1, Pawan Krishan1; Cardio Rheuma and Healing Touch City Clinic, Chandigarh and Rheumatologist, Fortis Multispecialty Hospital, Mohali, Punjab, 1Department of Pharmaceutical Sciences and Drug Research, Punjabi University Patiala, India

Background: Cardiovascular disease is the leading cause of morbidity and mortality in rheumatoid arthritis (RA). Similarities between atherosclerosis and RA and proven benefit of angiotensin receptor blockers and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors in atherosclerotic vascular disease provide strong rationale to investigate the impact of rosuvastatin (RVS) and olmesartan (OLME) on inflammatory disease activity and vascular inflammation in RA.

Objective: The objective of this study was to investigate the impact of RVS and OLME on inflammatory disease activity and vascular inflammation in RA.

Methods: A total of 84 RA patients were randomized to three groups to receive 24 weeks of treatment with RVS (10 mg/day, n = 28), OLME (10 mg/day, n = 28), and placebo (PL) (n = 28) as an adjunct to the existing stable antirheumatic drugs. Efficacy measures included the assessment of flow-mediated dilatation (FMD), endothelial progenitor cells (EPCs), serum nitrite, ICAM-1, VCAM-1, DAS28, Simplified Disease Activity Index (SDAI), tumor necrosis factor-α (TNF-α), interleukin (IL-1), IL-6, TBARS, functional Health Assessment Questionnaire disability index (HAQ-DI), quality of life (short form [SF]-36), and cardiovascular risk using SCORE chart.

Results: After treatment, FMD improved significantly in the RVS versus OLME versus PL groups from their baseline levels (RVS vs. PL [P < 0.01], OLME vs. PL [P ≤ 0.01], and RVS vs. OLME [P = 0.03]). The improvement in FMD after treatment with RVS was significantly greater than OLME (RVS vs. OLME [P = 0.03]). EPCs and nitrite levels improved significantly in both RVS and OLME groups. A significant reduction was found in ICAM-1 after RVS treatment (P < 0.01), whereas OLME significantly decreased VCAM-1 and TBARs (P = 0.04 and P = 0.01, respectively). Both RVS and OLME resulted in significant reductions of DAS28, SDAI, erythrocyte sedimentation rate, C-reactive protein (CRP), IL-6, and TNF-α versus PL. There was a significant reduction in the SCORE, HAQ-DI, and SF-36 scores after treatment with RVS and OLME.

Conclusion: RVS and OLME ameliorate inflammatory disease activity and vascular inflammation in RA. Both drugs lower the TNF-α and IL-6, which downregulates the production of CRP and nitric oxide and improved EPC population and FMD. Thus, both drugs have vasculoprotective and immunomodulatory effects mediated through anti-pro-inflammatory cytokine action.

  OC0051: NA Top

Eric Yen, Ram Raj Singh; University of California at Los Angeles (UCLA), Los Angeles, CA 90095, USA

Background/Objective: Disease burden is the impact of a health problem on a given area, which can be used to set health-care and research priorities and identify high-risk populations. The disease burden for autoimmune diseases is mostly unknown. Disease burden can be measured using a variety of indicators such as mortality, morbidity, or financial cost. Analysis of 62,843 systemic lupus erythematosus (SLE) deaths from the US-CDC's mortality database showed that SLE's mortality remains high relative to the general population's mortality. However, mortality rates may not adequately measure SLE burden because among those who died, a fifth died before reaching 40 years. Premature mortality is an important way to quantify disease burden. In constructing a measure of premature death, an arbitrary limit to life is chosen, and the years of potential life lost (YPLL) is calculated.

Methods: This is a population-based observational study. Death counts were obtained from the CDC-WONDER for 28 diseases, including SLE, top 15 CDC's leading causes of death, and 12 other autoimmune diseases. To calculate YPLL, each decedent's age at death from a specific disease was subtracted from a predetermined age of 75 years. The YPLL were then added together to yield the total YPLL.

Results: SLE was recorded as the cause of death in 28,411 women during 2000–2015. SLE ranked among the top 15 leading causes of death in reproductive age women (15–44 years) and #10 among women aged 15–24 years. YPLL for SLE was 304.2 thousand years in women aged 15–44 years and 66.2 thousand years in women aged 15–24 years. SLE-YPLL ranked #14 in women aged 15–44 years and #8 in women aged 15–24 years. Among autoimmune diseases, SLE ranked #2 in women aged 15–44 years and #1 in women aged 15–24 years.

Conclusion: SLE is among the leading causes of YPLL in young women, underscoring SLE as an important public health issue.

  OC0054: OMERACT Heel Enthesitis Magnetic Resonance Imaging Scoring system (HEMRIS) - Development and Preliminary validation Top

Ashish J Mathew1,2,3, Simon Krabbe2,3, Iris Eshed4, Frédérique Gandjbakhch5,6, Paul Bird7, Susanne J Pedersen3, Maria S Stoenoiu8, Violaine Foltz5, Daniel Glinatsi3, Robert G Lambert9, Kay Geert A Hermann10, Walter P Maksymowych11, Ida K Haugen12, Jacob L Jaremko9, René P Poggenborg3, Joel Paschke13, Jean-Denis Laredo14, Philippe Carron15, Philip G Conaghan16, Mikkel Østergaard2,3; 1Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, Tamil Nadu, India, 2Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, 3Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark, 4Department of Diagnostic Imaging, Sheba Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, 5Hôpitaux Universitaires Pitié Salpêtrière, Paris, France, 6Paris 6 University, Pierre Louis Institute of Epidemiology and Public Health, Paris, France, 7Division of Medicine, University of New South Wales, Sydney, Australia, 8Department of Rheumatology, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium, 9Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada, 10Department of Radiology, Arthritis Imaging Research Group, University Hospital Charité, Berlin, Germany, 11CaRE (Canadian Research Education) Arthritis and Department of Medicine, University of Alberta, Edmonton, Canada, 12Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway, 13CaRE (Canadian Research Education) Arthritis, Edmonton, Canada, 14Service de Radiologie, Hôpital Lariboisiére, APHP & Université Paris-Diderot, Paris, France, 15Department of Rheumatology, Ghent University Hospital, Ghent, Belgium, 16Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, & NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, United Kingdom

Objectives: The objective of this study was to develop and validate a magnetic resonance imaging (MRI) scoring system for heel enthesitis in spondyloarthropathy.

Methods: Consensus definitions of key pathologies within the OMERACT MRI in arthritis working group were framed, informed by a systematic literature review. Three internet-based multireader scoring exercises, with calibration sessions, were undertaken. Exercise 1 was for calibration and identifying pitfalls. Achilles tendon and plantar fascia entheses in ten ankle MRIs (sagittal T1-weighted and sagittal and axial T2-fat suppressed [T2wFS]) were scored 0–3 (no, mild, moderate, and severe, respectively) for peritendon hypersignal, intratendinous hypersignal, entheseal bone marrow edema, retrocalcaneal bursitis, tendon thickening, bone spur, and erosion by 15 readers with varying expertise in ankle MRI. Exercise 2 had 16 ankle MRIs, scored by 15 readers. In exercise 3, ankle MRIs (sagittal T2wFS) of 21 patients from a clinical trial, before and after biologics, were scored for inflammatory variables by 10 readers, blinded to chronological order. Reliability statistics (pair-wise single measures intraclass correlation coefficients [ICCs]) – absolute agreement for sum scores (patient level) and squared weights Cohen's kappa for individual scores (lesion level) were calculated. For assessing reliability among highly experienced readers, agreement between participating radiologists and three rheumatologists with best ICCs for inflammatory pathologies in exercise 2 was analyzed separately. Responsiveness of Heel Enthesitis Magnetic Resonance Imaging scoring (HEMRIS) was calculated by standardized response mean (SRM).

Results: Exercise 2: Mean pair-wise inter-reader ICCs were 0.64 (range: 0.17–0.93) for inflammatory variables and 0.45 (range 0.08–0.91) for structural variables. Median ICCs for inflammation and structural damage among the subset of readers were 0.85 and 0.68, respectively. Exercise 3: Mean pair-wise inter-reader ICCs for inflammatory variables were 0.81 (range: 0.57–0.95) for baseline and 0.81 (range: 0.57–0.92) for change scores. HEMRIS showed moderate responsiveness, with SRM of 0.70 (95% confidence interval: 0.38–1.05).

Conclusion: HEMRIS is reliable among trained readers and promising for clinical trials.

  OPC0030: Nuclear magnetic resonance (NMR) based Serum Metabolomics in Sarcoidosis and Tuberculosis – Search for a Biomarker Top

Avinash Jain, Amit Kumar, Harshit Singh, Mohit Kumar Rai, Saurabh Chaturvedi, Anupam Guleria, Alok Nath, Dinesh Kumar, Durga Prasanna Misra, Vikas Agarwal; Department of Clinical Immunology and Pulmmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Centre of Biomedical Research (CBMR), SGPGIMS, Lucknow, Uttar Pradesh, India

Introduction: Tuberculosis (TB), sarcoidosis, and granulomatous disorders often pose a diagnostic challenge. Diagnosis, requiring histopathological examination and culture, is often time consuming and results in delayed treatment.

Objective: Using nuclear magnetic resonance (NMR)-based metabolomics, a hypothesis-free approach, we wish to identify a noninvasive panel of biomarker(s) that may help us differentiate the two.

Methods: Normal healthy controls (NCs) and treatment-naïve patients of sarcoidosis and TB on antitubercular therapy, proven by tissue diagnosis and/or culture or GenExpert, were enrolled. Serum metabolic profiles were analyzed using 800 MHz NMR spectrometer and compared using orthogonal partial least-squares discriminant analysis and variable importance in projection statistics followed by univariate analysis using independent Student's t-test.

Results: A total of 35 sarcoidosis patients, 28 TB patients, and 54 NCs with a mean age of 40 ± 9.6, 30.3 ± 13.6, and 34.2 ± 5.2 years with a female:male ratio of 1.05:1, 2.5:1, and 1:1, respectively, were enrolled. The three groups showed good separation on the two-dimensional score plot [Figure 1] with goodness of fit (R2 = 0.94) and predictive power (Q2 = 0.89) with higher low-density lipoprotein/very low-density lipoprotein, polyunsaturated fatty acids, and glutamine in NCs followed by sarcoidosis patients and least in TB patients. Whereas lactate, leucine, isoleucine, and 3 hydroxybutyrate showed a reverse trend and were highest in patients with TB and least in NCs. Analysis of TB versus sarcoidosis using the same model showed R2 and Q2 of 0.97 and 0.96, respectively. [Table 1] highlights some of the metabolites of significance between sarcoidosis and TB with their area under receiver operating characteristic and P value. Compared to TB patients, the sera of sarcoidosis patients were characterized by significantly increased levels of glutamine and lipid metabolites, whereas acetate, citrulline, and various amino acids were significantly decreased.

Conclusion: The study underscores the potential of NMR-based serum metabolomics to differentiate sarcoidosis from TB. These preliminary results might pave way to the development of an early and efficient diagnostic modality.

  OPC0034: Targeted nuclear magnetic resonance-based serum metabolomics analysis revealed significantly higher phenylalanine/tyrosine ratio in pulmonary sarcoidosis patients compared to tuberculosis patients Top

Dinesh Kumar, Avinash Jain1, Amit Kumar, Anupam Guleria, Ritu Raj, Harshit Singh1, Mohit K Rai1, Saurabh Chaturvedi1, Alok Nath2, Durga P Misra1, Vikas Agarwal1; Centre of Biomedical Research, SGPGIMS, Departments of 1Clinical Immunology and 2Pulmonary Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India

Background: Currently, there are no reliable serum biomarkers to differentiate pulmonary sarcoidosis (SAR) from tuberculosis (TB) patients. Previous studies have shown the elevated phenylalanine-to-tyrosine (Phe/Tyr) ratio in infection and sepsis. Based on this, we hypothesized that serum Phe/Tyr ratio in TB patients will be higher compared to that in SAR patients.

Objective: The study objective was to compare serum Phe/Tyr ratio between TB and SAR patients and evaluate its utility as a biomarker.

Methods: Serum samples were collected from culture or GeneXpert-proven TB patients on treatment and treatment-naïve SAR patients. The serum metabolites were measured using the one-dimensional 1H CPMG nuclear magnetic resonance (NMR) spectra on 800 MHz NMR spectrometer equipped with a TCI CryoProbe™ (300 k). After processing of spectra, Phe and Tyr were measured with respect to internal reference metabolite formate assuming its concentration to be 10 mM in commercial software program CHENOMX, and the resulted ratio was compared using unpaired Student's t-test followed by receiver operating characteristic curve analysis.

Results: A total of 35 SAR and 28 TB patients, with a mean age of 40 ± 9.6 and 30.3 ± 13.6 years and a female:male ratio of 1.05:1 and 2.5:1, respectively, were enrolled. Contrary to expectation, the serum Phe/Tyr ratio was found to be significantly higher in SAR patients (mean value = 1.39) compared to TB patients (mean value = 1.08). Individually, the serum levels of Tyr were almost comparable with P < 0.1299; whereas, that of Phe were elevated in SAR (mean value ~27.4 mM) compared to TB (with mean value ~16.75 mM).

Discussion: Higher Phe/Tyr ratio suggested reduced Phe turnover in SAR, possibly, due to the reduced activity of 5,6,7,8-tetrahydrobiopterin, an oxidation-labile cofactor of Phe hydroxylase, possibly signifying the predominant activation of immune-mediated pro-inflammatory processes in SAR.

Conclusion: Serum profiling of Phe/Tyr ratio using NMR might be a useful tool to differentiate SAR patients from TB patients. However, future studies on large patient cohorts are required.

  OPC0178: Time to reach clinical quiescence and not serologic status affects the incidence of future flares in lupus: data from a lupus registry Top

Subodh Gururani, Phani Kumar Devarasetti1, Radhika Soanker2, Liza Rajasekhar3; Senior Resident, 1Assistant Professor, 3Professor, Department of Clinical Immunology and Rheumatology, 2Assistant Professor, Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Background: Achievement of clinical quiescence (CQ) and flare prevention is the treatment goal in lupus. Serological activity (SA) and tapering of therapy are believed to precipitate flares. Current definitions of remission/low disease activity state include clinical assessment, serological status and current treatment.

Objective: To report characteristics of patients in CQ and assess predictors of flare.

Methods: Consecutive SLE patients seen between October 2017 and August 2018 were screened. Those in CQ were included in this observational study. CQ was based on physician's global assessment of no clinically significant disease activity. SA was defined as low complements and/or abnormal dsDNA binding. Data collected from patient interview, outpatient notes and lupus registry forms. The registry has institutional ethical committee approval. Three groups: CQ with serological quiescence (CQSQ), CQ with SA (CQSA), CQ with serologic status unknown (CQSU) were identified. Flare after CQ was recorded. Time to CQ from last recorded disease activity, time to flare, time to stop steroids, continued immunosuppressive use, serologic status were compared between those with or without flares. Results mentioned as median (IQR), group comparisons using chi-square test and event time using Kaplan-Meier survival curves. Only hydroxychloroquine as treatment for SLE was considered off-treatment.

Results: Of 370 SLE patients screened, 52 met inclusion criteria. [Table 1] summarises patient characteristics. Time taken to stop steroids after CQ was 402 (203-747) days. Ten of 52 (19%) patients had subsequent flare. Time to flare was 567 (405-1393) days. Mean time to reach CQ was longer in those with flare than those without (422 vs 272 days; P=0.01, [Figure 1]) CQSA, CQSQ, CQSU groups were similar in time to flare, time to stop steroids, flares, use of steroids and immunosuppression (P>0.05).

Conclusion: Longer time to reach clinical quiescence increases risk of subsequent flare in lupus. Serologic activity is not associated with more flares.[2]


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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