IRACON 2017 - ORAL PRESENTATIONS
Year : 2017 | Volume
: 12 | Issue : 5 | Page : 2--15
|How to cite this article:|
. Oral Presentations.Indian J Rheumatol 2017;12:2-15
|How to cite this URL:|
. Oral Presentations. Indian J Rheumatol [serial online] 2017 [cited 2019 Nov 21 ];12:2-15
Available from: http://www.indianjrheumatol.com/text.asp?2017/12/5/2/219139
OB001 Rheumatoid Arthritis
Functional characterization of ADP ribosylation factor like protein (ARL15) expressed by rheumatoid arthritis synovial fibroblasts
Sujit Kashyap, Uma Kumar1, Patralika Chattopadhyay, Anuj Kumar Pandey, Maumita Kanjilal1, Chandrashekhar Yadav2, Debasis Sahu3, Amulya K Panda3, B K Thelma; Department of Genetics, University of Delhi South Campus, Departments of 1Rheumatology and 2Orthopaedics, All India Institute of Medical Sciences, 3National institute of Immunology, New Delhi, India
Background: We reported ARL15 as a novel susceptibility gene in a recent genome wide association study performed in a north Indian rheumatoid arthritis (RA) cohort and also documented its influence on adiponectin levels in RA patients. However, the role of ARL15 or ARF family genes including ARF1, ARF6 in RA etiology remains unknown.
Objectives: i) To establish the expression of ARL15 in rheumatoid arthritis synovial fibroblasts (RASF); ii) Functional characterization of ARL15 using a knockdown and RNAseq approach; and iii) To explore its therapeutic role using CIA mouse model.
Methodology: Synovial fluid and tissue samples were collected from RA patients with informed consent. Homogeneity of cells was checked by FACS and presence of ARL15 in RASF was tested by RT-PCR and western blots. Candidate gene expression on TNF induction and siRNA knockdown was evaluated by RT-PCR and global expression profiling in knock down and control cells was captured by RNAseq. Role of ARL15 in RASF mobility was determined by invasion and migration assays and in apoptosis by Annexin V staining. Correlation between hypoxia and ARL15 expression was tested using A172 cancer cells. Attempts to assess therapeutic relevance of ARL15 were made using CIA mouse model.
Results: RT-PCR and western blot showed the presence of ARL15 in FACS confirmed RASF. Differential expression of Adiponectin, Adiponectin receptor, GAPDH and IL6 were observed in RASF upon ARL15 knockdown. RNAseq validated these findings and in addition revealed differential expression of apoptosis and hypoxia related genes. Further, ARL15 did not express under hypoxic condition in A172 cells. Cells with ARL15 knock down showed less invasion and migration but more apoptosis. CIA model showed reduced swelling in mice treated with ARL15 mAb [Figure 1].[INLINE:1]
Conclusions: ARF genes including ARL15 seem to be involved in RA biology most likely through inflammation and apoptosis, with its anti inflammatory effect being evidenced in CIA mouse model.
OB002 Rheumatoid Arthritis
CD39 positive regulatory T cell frequency predicts response to methotrexate in rheumatoid arthritis
Vikas Gupta, Shobhita Katiyar, Ankita Singh, Ramnath Misra, Amita Aggarwal; Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Background: About 30-40% of patients with RA do not respond to MTX, the first-line therapy in RA. Early identification of responders may allow use of alternative DMARDs in patients unlikely to respond, thus preventing long-term damage. CD39, an ectonucleotidase highly expressed on regulatory T cells (Tregs), is responsible for production of adenosine, an important anti-inflammatory mediator of MTX action. CD39 expression on Tregs improves their suppressive capacity, and hence, CD39+ Tregs could play a role in predicting response to MTX.
Objectives: We aimed to study the role of CD39+ Treg frequency as a biomarker for MTX responsiveness in RA.
Methods: Patients with active RA (fulfilling 2010 ACR/EULAR classification criteria and having DAS28-CRP >3.2) who were naive to DMARDs were enrolled. Frequency of CD39+ Tregs (CD39+CD4+CD25+FoxP3+ T cells) was determined by flow cytometry in peripheral blood before start of therapy. After 4 months of MTX monotherapy (no corticosteroids were given), patients were classified into two groups based on EULAR response criteria: responders (moderate/good response; MTX-R) and non-responders (MTX-NR). All patients were genotyped for single nucleotide polymorphism (SNP) rs11188513 in CD39 gene using TaqMan probe method. The data was analysed using non-parametric tests.
Results: 70 patients were enrolled (60 females, median age: 39 years and median disease duration: 24 months). The mean DAS28-CRP was 5.19 Â ± 1.04. After 4 months of follow-up, 54 patients were classified as MTX-R and 16 as MTX-NR. There was no difference in the two groups as regards age, disease duration, disease activity or baseline frequency of Tregs [1.4% (1.0%-2.3%) vs 1.1% (0.6%-1.9%), p = NS]. However, the baseline CD39+ Treg frequency was significantly higher in the MTX-R compared with the MTX-NR [78.0% (66.9%-87.5%) vs 67.8% (23.3%-84.3%), p < 0.05]. At a cut-off of CD39+ Treg frequency of 75.1%, the positive predictive value (PPV) to identify responders was 86%. CC genotype at SNP rs11188513 of CD39 was associated with a lower frequency of CD39+ Tregs (p < 0.001).
Conclusion: Higher frequency of CD39+ Tregs in peripheral blood is associated with responsiveness to MTX in RA and hence, could be considered a potential biomarker for prediction of response to MTX.
OB003 Rheumatoid Arthritis
Theaflavin 3, 3'digallate (TF3) in the maintenance of homeostasis between apoptosis and autophagosome in fibroblast like synoviocytes in rheumatoid arthritis
Sanchaita Misra, Dipanjan Bhattacharjee#, Debanjali Dasgupta&, Sulagna Chatterjee#, Ayindrila Saha#, Sudipta Chatterjee#, Arghya Chattopadhyay#, Pradyot Sinhamahapatra#, Alakendu Ghosh@; Department of Rheumatology, IPGMER, Kolkatta, #Department of Rheumatology, PGIMS Chandigarh, &School of Digestive and Liver Disease Institute of Post Graduate and Medical Education, #Associate professor department of rheumatology, @Department of Rheumatology, IPGMER, Kolkatta
Background: Rheumatoid arthritis is characterized by inflammation resulting from onset of vascularity and angiogenesis in synovial tissue. This further leads to modulation in apoptotic pathways. Alteration of apoptotic pathways counteract with autophagmosomal machineries which induce cell survivability by halting the apoptotic signaling. Anti-inflammatory drugs are capable of reducing cytokine activity but are unable to restore disrupted homeostasis between autophagy and apoptosis in FLS of RA. Active compounds of black tea especially TF3 has been reported to target the inflammatory and proliferative cells in other inflammatory disease models and induce them to initiate programmed cell death.
Objectives: To study the down regulation of autophagy and induction of apoptosis in FLS from patients with RA by TF3 in dose depended manner.
Methods: Synovial fluid was collected from 15 RA patients. FLS were isolated from the same and cultured in vitro. The cells were treated with/without TF3 (625nM); and inflammatory markers and secretory cytokines were quantified by ELISA. FLS viability was determined by MTT assay. Cell death analysis was performed by flowcytometry (Annexin V- FITC). Expression of autophagosomal and apoptotic proteins were quantified by immunocytochemistry and immunoblot assays.
Results: TF3 significantly decreased the pro-inflammatory cytokines (Tnf-α, IL-6) hypoxia inducible factor (Hif-1 α) and other angiogenic markers (Ang-1, VEGF) which were high in FLS from RA patients [Table 1]. Chronic Inflammation was inversely correlated with low caspases expression (r2= -0.56) in FLS which was restored after TF3 treatment. TF3 administration successfully reinstated autophagmosomal protein expressions in FLS. Apoptosis was induced in FLS from RA patients after TF3 treatment (10% to 28%).[INLINE:2]
Conclusion: Disruption in homeostasis between apoptosis and autophagy might be an underlying phenomenon in progression of pathophysiology in FLS of RA patients, fueled by inflammatory mediators, enhanced vascularity and angiogenesis. Administration of TF3 successfully balanced the homeostasis to normal level by inducing apoptosis in FLS.
OB004 Lupus APS Sjogren's Syndrome
TCR signal fine-tuning molecules are altered in systemic autoimmune disease due to increased ubiquitination
Julia Pinkhasov1, Ram Raj Singh1,2,3,4; 1Department of Medicine, Autoimmunity and Tolerance Laboratory, Division of Rheumatology, David Geffen School of Medicine at University of California Los Angeles, 2Interdepartmental Program in Molecular Toxicology, David Geffen School of Medicine at University of California Los Angeles, 3Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at University of California Los Angeles, 4Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
Background/Purpose: T-cell selection in the thymus is determined by the avidity of T-cell receptor (TCR) for self-ligand-MHC. Since this process is dependent on the somatically generated receptors against the internal antigenic environment, all T-cells are inherently self-reactive to some degree. Hence, a signalling threshold must be established whereby overtly high self-avidity, potentially pathogenic, T-cells are removed, while allowing other lower self-avidity T-cells to survive. We investigated the mechanisms of altered expression of potential TCR signal fine-tuning (TFT) molecules, and their role in T-cell signalling defects using a model of multi-system autoimmune disease.
Methods: The availability of murine strains that develop autoimmune disease resembling human SLE enables one to study the preclinical events in the pathogenesis. We used MRL/MpJ-Fas+/+ (MRL+/+) mice that develop SLE at 8-10-months age, congenic MRL/MpJ-Faslpr/lpr (MRL/lpr) mice that develop SLE at 3-4-months, and MHC-matched C3H controls.
Results: We found the altered expression patterns of TFTs on thymocytes from MRL/lpr and MRL+/+ mice compared to C3H controls; specifically, negative-regulator TFTs were reduced, while a positive-regulator was increased. thymocytes from pre-clinical MRL+/+ and MRL/lpr mice showed increased activation and phosphokinase signal upon ex vivo stimulation, which were restored to near-normal levels in presence of a CD5-agonist. Unexpectedly, we observed reduced TFTs in activated peripheral T-cells after disease onset. The reduced levels of negative TFTs correlated with increased responsiveness to TCR-stimulation and to weak antigenic ligands. The reduced expression of TFTs in periphery was not due to their decreased transcripts, but rather to activation-induced post-translational modification due to increased ubiquitination leading to targeted protein degradation. This was associated with altered expression of E3 ubiquitin ligases cbl-b, traf6, grail and itch in MRL mice.
Conclusion: T-cells are able to tune the expression levels of TFTs post-development, likely by targeted protein degradation using the ubiquitin cycling pathway. We propose that the ability of T-cells to alter their internal signal threshold by altering TFT expression is a novel mechanism for T-cells to escape peripheral tolerance and perpetuate autoimmune disease. Restoration of TCR signals to normal upon increased signalling through a TFT raises hope for a new avenue of treating systemic autoimmune diseases.
OB005 Lupus APS Sjogren's Syndrome
Association between ITGAM, STAT4, TNFSF4 and TNFAIP3 gene polymorphisms and susceptibility to systemic lupus erythematosus in North Indian Population
Vikas Gupta, Sandeep Kumar, Avadhesh Pratap, Rajeev Singh, Reena Kumari, Amita Aggarwal, Ramnath Misra; Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, 1Department of Biochemistry, King George Medical University, Lucknow, Uttar Pradesh, India
Background: Several susceptibility genes have been associated with Systemic Lupus Erythematosus (SLE) across different populations worldwide. However, data on association between genetic polymorphisms and SLE from Indian population are lacking.
Objectives: We aimed to replicate the association of single nucleotide polymorphisms (SNPs) in ITGAM, STAT4, TNFSF4 and TNFAIP3 genes with susceptibility to SLE in a north Indian population. We also aimed to study the genetic relations between these SNPs and sub-phenotypes of SLE.
Methods: 394 SLE patients (classified according to 1997 ACR classification criteria for SLE) and 583 unrelated healthy controls were enrolled. All samples were genotyped for SNPs in ITGAM (rs1143679), STAT4 (rs7574865), TNFSF4 (rs2205960), and TNFAIP3 (rs5029939) using TaqMan genotyping assay in Roche LC480 real-time polymerase chain reaction (PCR) system. A case-control association study and a genotype phenotype correlation were performed.
Results: The mean age of the SLE patients was 31 years and 94.4% were females. Allelic and genotypic frequencies did not deviate from Hardy-Weinberg equilibrium in the controls (p > 0.05). On allele contrast, significant association with susceptibility to SLE was detected with polymorphisms in ITGAM (A vs G, OR=1.73, 95% CI= 1.30-2.30, p < 0.001), STAT4 (T vs G, OR= 1.38, 95% CI= 1.13-1.69, p < 0.01), TNFSF4 (T vs G, OR= 1.33, 95% CI= 1.08-1.64, p < 0.01), and TNFAIP3 (G vs C, OR= 1.91, 95% CI= 1.27-2.85, p < 0.01) genes. All four SNPs were associated with SLE under a dominant inheritance model with odds ratio (OR) of 1.47 (95% CI= 1.07-2.04, p < 0.05) for ITGAM, 1.38 (95% CI= 1.06-1.78, p < 0.05) for STAT4, 1.30 (95% CI= 1.01-1.69, p < 0.05) for TNFSF4, and 1.90 (95% CI= 1.25-2.90, p < 0.01) for TNFAIP3 genes. Under recessive model of inheritance, significant association was found with ITGAM (OR= 4.87, 95% CI= 2.17 - 10.91, p < 0.001), STAT4 (OR= 1.82, 95% CI= 1.19-2.77, p < 0.01) and TNFSF4 (OR= 1.84, 95% CI= 1.13 - 3.00, p < 0.05).
Conclusion: Single nucleotide polymorphisms in ITGAM, STAT4, TNFSF4 and TNFAIP3 genes are associated with susceptibility to SLE in North Indian Population.
OB006 Lupus APS Sjogren's Syndrome
Role of innate B cells in the pathogenesis of pulmonary lupus and vasculitis
Ram Raj Singh1,2,3,4, Priti Prasad1,2, Michael Fishbein3; 1Department of MedicineAutoimmunity and Tolerance Laboratory, Division of Rheumatology, David Geffen School of Medicine at University of California Los Angeles, 2Molecular Toxicology Interdepartmental Program, David Geffen School of Medicine at University of California Los Angeles. 3Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California Los Angeles, 4Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
Background: Lung is involved in up to 50% patients with SLE. Among pulmonary-lupus manifestations, pneumonitis, vasculitis and diffuse alveolar hemorrhage (DAH) carry a high mortality, and are without any effective treatment. Advances in its pathogenesis have been hampered because of the heterogeneity of clinical findings, paucity of access to affected tissues, and the lack of suitable model systems. Hydrocarbon oil, 2,6,10,14-tetramethylpentadecane (TMPD), induces lupus-like autoantibodies, nephritis, arthritis, pneumonitis, and DAH. We examined the role of B-cells in pulmonary-lupus using this model.
Methods: We injected TMPD to induce pulmonary-lupus in C57BL/6 mice and analysed B-cell subsets. We injected CD19-/- mice (deficient in B1a B-cells) and wild-type mice with 500Î¼l TMPD intraperitoneally. We adoptively transferred wild-type peritoneal-fluid cells enriched in B1 B-cells into CD19-/- and in IgÎ¼-/- mice (have no B-cells). We assessed disease using semi quantitative and quantitative measures.
Results: 73% of 62 TMPD-injected wild-type mice exhibited weight-loss, pneumonitis, vasculitis, and/or DAH compared to none of controls injected with hydrocarbon oil hexadecane or PBS/sham. At earlier time points prior to histopathological changes, while both hexadecane and TMPD caused myeloid cell abnormalities, only TMPD caused lung-infiltration with B-cells that expressed B1 B-cell subset markers: CD19+CD11b+/CD19+CD5+. B1 B-cells were simultaneously reduced in their usual location (peritoneal cavity). CD19-/- mice that have less B1a B-cells developed less DAH, and less B-cell lung infiltration than wild-type mice. The adoptive transfer of wild-type peritoneal-fluid cells into the peritoneum of CD19-/- or IgÎ¼-/- mice induced more DAH/pneumonitis than the respective knockout recipients reconstituted with CD19-/- B-cells. The adoptive transfer of CD45.1+ wild-type peritoneal-fluid cells into the peritoneum of CD45.2+CD19-/- recipients led to lung-infiltration with CD45.1+ B-cells. TMPD-exposed lungs had a differential expression of a set of immune/inflammatory genes, including chemokine Cxcl13 that is known to drive B1 B-cells' migration.
Conclusion: TMPD-exposure induces B1 B-cells to traffic from the peritoneum into lungs and cause pneumonitis/DAH. These observations identify trafficking of a specific B-cell subset as a potential target for therapy, with implications for pulmonary-lupus, vasculitis and other rheumatic diseases. Furthermore, humans can be exposed to hydrocarbon oils present in petroleum products and mineral oils.
OB007 Lupus APS Sjogren's Syndrome
Self-glycerophospholipids suppress immune-mediated inflammation via induction of myeloid-derived suppressor cells
Ram Raj Singh, Cynthia Tran, Ramesh Halder; Autoimmunity and Tolerance Laboratory, Division of Rheumatology, Departments of Medicine and 1Pathology and Laboratory Medicine, David Geffen School of Medicine at University of California Los Angeles, 2Interdepartmental Program in Molecular Toxicology, David Geffen School of Medicine at University of California Los Angeles, 3Jonsson Comprehensive Cancer Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
Background/Purpose: Lipids function as components of biological membranes, signaling molecules, and energy-storage molecules. Glycerophospholipids (GPL) are the most abundant membrane lipids. Their glycerol backbone is esterified to phosphoric acid, resulting in the formation of phosphatidic acid (PA), from which all other GPLs are formed by the addition of a polar headgroup like choline, ethanolamine, glycerol, inositol, and serine, producing the main phospholipids in the cell, namely phosphatidylcholine (PC), phosphatidylethanolamine (PE), phosphatidylglycerol (PG), phosphatidylinositol (PI) and phosphatidylserine (PS), respectively. GPLs have been eluted and identified by mass spectrometry as natural human CD1d ligands, and PC and PE have been eluted from murine CD1d. However, the functions of T cells that recognize self-GPLs are not known.
Methods: CD1d tetramers were loaded with various GPL antigens, and cells analyzed by flow cytometry. Cell-cell interactions between GPL-reactive T-cells and other immune cells were analyzed using in vivo and in vitro assays. In vivo effects of GPLs were tested in autoimmune animal models.
Results: CD1d tetramers loaded with GPLs, namely PA, PC, PE, PI, PS and BMP, identify 0.4â€"4% T cells in the lymphoid organs of normal and autoimmune-prone NZB/NZW and NZM.2328 mice. GPL-reactive T-cells donâ€™t recognize glycolipid-loaded tetramers and donâ€™t respond to glycolipid Î±GalCer, suggesting that GPL-reactive T cells are distinct from other CD1d-restricted, invariant natural killer T-cells. GPL-reactive T-cells expand, express CD69, and produce cytokines upon in vivo priming. However, all self-GPL antigens tested potently inhibited the proliferation and cytokine production by invariant natural killer T-cells via mobilization and migration of monocytic myeloid-derived suppressor cells into peripheral organs. These myeloid-derived suppressor cells inhibited invariant natural killer T-cells via interleukin-10. Treatment with a GPL antigen ameliorated autoimmune hepatitis, reduced pro-inflammatory cytokines and granulocyte accumulation, but recruited interleukin-10 producing myeloid derived suppressor cells that upon adoptive transfer protected against autoimmune disease in an animal model.
Conclusion: Normal immune repertoire contains T-cells reactive to self-GPLs, which ameliorate autoimmune disease via mobilization and migration of a subset of myeloid-derived suppressor cells. These novel observations have important implications for conditions with altered lipid metabolism and inflammation such as atherosclerosis and autoimmune disease.
OB008 Scleroderma, Myositis and Overlap
Tadalafil reduces skin fibrosis and profibrotic genes expression in patients with systemic sclerosis
Sakir Ahmed, Mohit K Rai, Durga P Misra, Vikas Agarwal; Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Background: Currently, drugs that modify skin fibrosis in Systemic Sclerosis (SSc) have efficacy in certain subgroups of patients only. Phosphodiesterase-5 inhibitors (PDE5i) are known to reduce fibrosis in Peyronie's disease and renal fibrosis. We studied the efficacy of tadalafil, a long acting PDE5i, in reducing the skin fibrosis in SSc.
Methods: In this prospective open-labeled study, 24 patients meeting ACR 2013 classification criteria for systemic sclerosis were recruited. Twelve received tadalafil in addition to standard of care whereas the rest were continued on standard of care. Demographic and clinical details including Modified Rodnan Skin Score (MRSS) were recorded at baseline and at 6 months. Paired forearm skin biopsies of 5 mm diameter were taken at baseline and at 6 months. Expression of profibrotic genes COMP, THBS1, SIGLEC1, IFI44, TN-C, COL1A1, COL1A2, ACTA2 and CTGF in skin biopsies were compared to housekeeping gene GAPDH using real time polymerase chain reaction.
Results: Baseline characteristics were similar in both the groups. One patient was lost to follow-up in each group. Amongst patients on Tadalafil, median mRSS decreased from 22 to 13 (p= 0.005) whereas median mRSS in the other group had a statistically non-significant increase from 15 to 19 (p=1) at 6 months [Figure 1]. In the Tadalafil group, there was decrease in the expression of COMP, SIGLEC1, CTGF and IFI44 that was statistically significant. In the other group, there was significant increase in the expression of IFI44, THBS1 and TN-C that was absent in the Tadalafil group. Overall change in mRSS (Î"mRSS) correlated with change in SIGLEC1, IFI44, TBHS1 and COL1A1 (Spearman; p<0.05).[INLINE:3]
Conclusion: Tadalafil significantly reduced the skin fibrosis in SSc with down-regulation or prevention of upregulation (or both) in 6 of the 9 pro-fibrotic genes tested.
OB009 Scleroderma, Myositis and Overlap
5-HT2 and 5-HT2B antagonism attenuate non-canonical signaling in fibrotic phenotype of human adult dermal fibroblasts
Vikas Agarwal, Saurabh Chaturvedi, Durga Prasanna Misra, Harshit Singh, Mohit Kumar Rai, Ravi Mishra, Kritika Singh; Department of Clinical Immunology, SGPGIMS, Lucknow, Uttar Pradesh, India
Background: 5-hydroxytryptamine (5-HT; serotonin) strongly induces extracellular matrix synthesis in interstitial fibroblasts in a Transforming growth factor beta 1 (TGF-Î²1) dependent manner. We aimed to evaluate the anti-fibrotic properties of 5-HT2 and 5-HT2B receptor inhibitors, Terguride and SB 204741, respectively in Human Adult Dermal Fibroblasts (HADF).
Objectives: To evaluate the effect of inhibitors of 5HT2 (Terguride) and 5 HT2B (SB 204741) on: 1- Pro and anti-fibrotic gene expression at mRNA and protein level on human adult dermal fibroblasts 2- Effect of compounds on SMAD and Non-SMAD pathway.
Methods: HADF (Himedia, Lot No. 222342, 42 years female, scleroderma patient) were sub passaged with 0.25% trypsin-EDTA. In first strategy, cells were incubated with 5-HT-1 μM for 1 hr and later with 5-HT-1 μM and (Terguride, SB 204741-1 μM, each) for 24 hr. In second strategy, cells were pre-treated with (Terguride, SB 204741-1 μM, each) for 1 hr and later with only 5-HT-1 μM for 24 hr. Real time quantitative PCR for pro-fibrotic (TGF-Î²1, Col1a1, Col1a2, ACTA2, CTGF and FN1) and anti-fibrotic genes (MMP2/TIMP1) expression was performed. Type I collagen and Î±-SMA, phosphorylation status of Smad-3 and ERK1/2 was examined by immunoblotting [Figure 1].[INLINE:4]
Results: In 5-HT stimulated HADF, upregulated expression of Col1a1, Col1a2, ACTA2, CTGF and FN1 (p<0.05) mRNA at 24 hr was observed. Co-culture of HADF with 5-HT2 and 5-HT2B receptor antagonists, Terguride and SB 204741, significantly reduced pro-fibrotic genes expression (p<0.05) in both the strategies. Effect on anti-fibrotic genes mRNA in both the strategies was not affected. Pre-treatment with Terguride and SB204741 decreased the production of type 1 collagen and Î±-SMA significantly (p<0.05). 5-HT dose-dependently increased the mRNA levels of TGF-Î²1. Terguride and SB 204741 did not influence Smad-3 phosphorylation (canonical pathway) rather they significantly reduced ERK1/2 phosphorylation (non-canonical pathway) (p<0.05).
Conclusion: 5-HT2 and 5-HT2B receptor antagonists reduce pro-fibrotic mRNA expression in 5-HT stimulated HADF by suppressing TGF-Î²1 mediated non-canonical pathway.
OB010 Scleroderma, Myositis and Overlap
Distinctive metabolic patterns of myositis patients revealed by 1H NMR based Serum Metabolomics
Anupam Guleria, Latika Gupta1, Puja Srivastava1, Amit Kumar, Umesh Kumar, Dinesh Kumar, Ramnath Misra1*; Centre of Biomedical Research, SGPGIMS, 1Department of Clinical Immunology, SGPGIMS, Lucknow, Uttar Pradesh, India
Background: Dysregulation of cellular bioenergetics is the patho-physiologic hallmark of muscle weakness in myositis. NMR based serum metabolomics can detect changes in various metabolites related to cellular bioenergetics such as glucose, citrate, pyruvate, creatinine and creatinine phosphate; thus can be put to use for early diagnosis. Objective: To identify the serum metabolic patterns of myositis and further to investigate if there are specific metabolic alterations associated with juvenile myositis compared to adulthood myositis.
Methods: The serum samples were collected from 74 myositis patients: 42 dermatomyositis (DM), 16 polymyositis (PM) and 16 juvenile DM (JDM), median age= 29 years, sex M/F ratio=19:57) and 91 normal controls (median age= 28 years, sex M/F ratio=22:69) fulfilling the Bohan and Peter's criteria . The serum metabolic profiles were obtained at 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 (VIP) statistics [Figure 1B] and further evaluated for statistical significance [p-value <0.05, Figure 1C].[INLINE:5]
Results: and discussion: An exquisite separation in 2D score plot of PLS-DA between myositis and NC groups suggested that the metabolic profiles of IIM patients are distinctively different from normal controls [Figure 1]A. The metabolomics profiling of Polymyositis did not differ from those with Dermatomyositis. However, the metabolomics signatures in children with juvenile Dermatomyositis differed from adult myositis patients. Sera of IIM patients were characterized by increased serum levels of Glucose, Creatine/creatinine, and amino acids (alanine, glutamate, lysine, arginine, histidine, tyrosine, phenylalanine and branched chain amino acids), whereas the serum levels of lipid/membrane metabolites including low/very-low density lipoproteins (LDL/VLDL), PUFA, choline and Glycerophosphocholine and glutamine were found to be decreased significantly compared with normal controls. These metabolic alterations clearly suggested that the myositis patients exhibit poorly regulated glucose metabolism, activated Glutaminolysis, aberrant proteolysis and lipid/membrane metabolism. The increased serum levels of amino acids in IIM patients might be related to increased serum levels of muscle enzymes and their further degradation.
Conclusion: IIM patients exhibit distinctive metabolomics signatures. NMR based serum metabolic profiling can facilitate early diagnosis of patients with inflammatory myositis.
OB011 Scleroderma, Myositis and Overlap
Nuclear magnetic resonance based metabolomics study identifies highly discriminatory metabolites in 87 systemic sclerosis patients
Mohit Kumar Rai, Sakir Ahmed, Durgesh Dubey, Atul Rawat, Durga P Misra, Dinesh Kumar, Vikas Agarwal; Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Background/Purpose: Proton based Nuclear Magnetic Resonance (1H NMR) can identify concentration of hundreds of small molecules in body fluids. A hypothesis-free approach was used to analyze metabolic perturbations in sera of Systemic Sclerosis (SSc) to identify potential biomarkers of the disease
Methods: Sera from 87 patients meeting ACR 1980 criteria for Systemic Sclerosis, and 40 age and sex similar controls, was analyzed using 1H NMR spectroscopy coupled with multivariate statistical analysis.
Results: There was clear distinction between SSc and healthy controls on Partial Least Square-Discriminate Analysis (PLS-DA) [R2= 0.98]. Several metabolites of discriminatory relevance were identified, and further evaluated using analysis of variance (ANOVA) and Receiver Operator Curve (ROC) analysis. Methylamine, nitrosodimethylamine (NDMA), citrate and malonate were 4 metabolites that had maximum area under curve (AUC> 0.95) in distinguishing SSc from controls [Figure 1]. Methylamine and NDMA were uniformly elevated almost exclusively in SSc patients.[INLINE:6]
Conclusion: H1 NMR based metabolomics identified metabolites that have high discriminative value for SSc. Methylamine and NDMA may be potential biomarkers. Their possible roles in disease pathogenesis also need to be explored.
Monocytes produce more pro-inflammatory cytokines in response to endogenous toll like receptor ligands in patients with juvenile and adult spondyloarthropathies
Shruti Bhattacharya, Ramnath Mishra, Amita Aggarwal; Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Introduction: Our recent data shows that serum levels of Myeloid Related Protein (MRP) 8/14 and Tenascin C (TNC), endogenous TLR4 ligands are higher in SpA patients. Thus, we studied the effect of endogenous and conventional TLR ligands on monocytes of SpA patients.
Methods: Patients with ankylosing spondylitis (AS), children with enthesitis related arthritis (ERA) and healthy controls (HC) were studied. Diluted whole blood or SFMC were stimulated with TNC, MRP8 or LPS. Intracellular cytokine production was measured by flow cytometry and cytokines in culture supernatant by ELISA.
Results: 52 ERA, 47 AS patients and 25 HC were included. At baseline, ERA patients (50.19 Â± 69.37) had higher frequency of TNF-Î± producing monocytes compared to HC (15.17 Â± 13.60; p <0.01). Simulation with MRP8 led to a significant increase in TNFÎ± producing monocyte frequency in AS (117.38 Â± 129.96) and ERA patients (168.83 Â± 115.42) compared to HC (109.04 Â± 67.58; p <0.05). Similar results were seen with TNC. The frequency of IL-6 producing monocytes also increased post stimulation with TNC and MRP8 in SpA patients compared to HC (p <0.0001). In culture supernatants, AS (69.26 Â± 66.29) and ERA (50.19 Â± 69.37) patients showed significantly higher TNF-Î± production at baseline compared to HC (15.17 Â± 13.60; p <0.05) as well as post stimulation by MRP8 (AS 117.38 Â± 129.96; ERA 168.83 Â± 115.42) and TNC (AS 97.45 Â± 110.98; ERA 82.51 Â± 64.12). Similar results were seen for IL-6 production. AS and ERA patients also showed higher MRP8 production at baseline (AS- 54.96 Â± 13.12, ERA- 52.09 Â± 23.51, HC- 19.05 Â± 8.16) as well as post stimulation with LPS (AS- 117.85 Â± 26.74, ERA- 105.10 Â± 25.72, HC- 59.60 Â± 14.69). Same trend was also observed in TNC production.
Conclusion: AS and ERA patients have pre-activated monocytes in peripheral circulation. Endogenous ligands further stimulate monocytes. This may be contributing to production of pro-inflammatory cytokines and sustained immune-inflammation.
OC013 Rheumatoid Arthritis
Neutrophil and lymphocyte ratio is a better indicator of sustained remission than cytokine and B and T cell profile in rheumatoid arthritis
S Chandrashekara, C L Deepak, P Renuka, K Anupama; Chanre Rheumatology and Immunology Centre, Bengaluru, Kranataka, India
Aim: Imbalance in various leukocyte sub-population and cytokines are implicated in the modulation of clinical course in rheumatoid arthritis (RA). Hence their profile can be a predictor of disease. The current preliminary study investigated the different cytokines profile and cellular phenotypes/populations as a predictor of achieving sustained remission in RA.
Methods: Fifty-two treated RA patients (2010 ACR/EULAR criteria) who were in remission (DAS28CRP (3) â‰¤2.6) were recruited for the study. The patientâ€™s demographic, clinical and laboratory parameters were collected. Whole blood heparinized samples and serum were collected after the patient had achieved DAS score of 2.6 less in previous 3 month visit. The samples were analyzed cytokines: IL-6, IL-10 and TNF-Î± and cell count using markers of CD3+, CD4+, Fox P3+ and CD19+ cell phenotypes. The patients were followed-up at 3rd and 6th month and DAS28-CRP (3) calculated. Patients with sustained DAS28-CRP (3) score â‰¤2.6 at all the three visits were considered to be in sustained remission. Patients with increasing score in any follow-up visit were considered as relapse of RA.
Results: 43 patients were available for assessing sustained remission. 30 RA patients had sustained remission and 13 had relapse. Mean (SD) age was 47.05 (9.27) with 4 male and 37 females. Duration of illness was 60 mths (7-240 mths). The regression estimates demonstrated that RA patients with baseline NLR â‰¤2 were 12.85 times more likely to achieve sustained remission than those with NLR >4. Patients with NLR >2â‰¤4 were 3.12 times more likely to have sustained remission than the reference group. Odds ratio of Fox P3+ was 1 indicating no difference in the counts between the disease activity groups. Cytokine profile were not predicting the sustained remission.
Conclusion: NLR â‰¤2 may indicate RA patients achieving sustained remission. Further studies with large sample size are required to substantiate the findings.
OC014 Lupus APS Sjogren's Syndrome
Comparison of tacrolimus-azathioprine combination versus cyclophosphamide for induction treatment of proliferative lupus nephritis
Atanu Pal, Arpita Roychowdhury, Parasar Ghosh1; Departments of Nephrology and 1Rheumatology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
Background: The management of proliferative lupus nephritis is still evolving. Considering the complicated pathogenesis of lupus nephritis involving humoral as well as cellular immunity, a multidrug multitarget regimen may be a rational approach. Recent trials showing benefit in class IV and V lupus using multitarget approach used mycophenolate mofetyl which is replaced here by azathioprine considering cost appropriacy and a lesser potential for sepsis. Study design and settings: We report the comparison of tacrolimus-azathioprine combination regimen and intravenous cyclophosphamide (IVCY) as induction treatment for proliferative lupus nephritis in an open label randomized controlled study from a tertiary center in eastern India.
Intervention: Fifty eight patients with lupus nephritis classes III and IV, with or without evidence of class V lesions, were randomly assigned to tacrolimus (0.075 mg/kg) with azathioprine (2 mg/kg) or monthly intravenous cyclophosphamide (500 mg/m2). Both groups received 3 pulsed doses of methylprednisolone and subsequently, prednisolone was given at doses of 0.5 mg/kg/day for the next 1 month and then tapered as tolerated to 10 mg or less by 3 months.
Outcomes: The primary end point was achievement of complete renal remission. Secondary end points included partial remission of lupus nephritis, decrease of proteinuria, disease activity scoring and safety.
Results: Complete remission occurred in 77.41% patients on the Tacrolimus-Azathioprine regimen and in 72.7% patients in the cyclophosphamide arm (p=0.9). Secondary end points were also similar between treatment groups. Major infective complications requiring hospital admission in the triple drug regimen [1 (3.2%) vs. 4(18.1%)] were less and the two groups had non-significant differences in safety and adverse events.
Limitations: Short duration of study follow up.
Conclusion: The Tacrolimus-Azathioprine combination regimen is at least as efficacious and safe as the IVCY regimen.
OC015 Lupus APS Sjogren's Syndrome
Study of familial aggregation of autoimmune diseases in Asian Indian patients (Probands) with lupus
Arvind G, Gautham Arunachal1, Suvrat Arya, Devaki Shanmugasundaram2, Lakshmanan Jeyaseelan2, T Satish Kumar3, Sumita Danda1, Debashish Danda; Departments of Clinical Immunology and Rheumatology, 1Medical Genetics, 2Biostatistics and 3Pediatric Rheumatology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
Background: SLE and other auto-immune diseases (AID) tend to co-aggregate in families, making positive family history a risk factor for SLE.
Objective: We aimed to calculate familial aggregation of rheumatic AIDs including SLE, in lupus pro-bands and to compare familial and sporadic lupus pro-bands in our cohort.
Methods: We studied families of 157 consecutive lupus pro-bands satisfying the 2012 SLICC Classification Criteria in a hospital-based, cross-sectional design. We documented 3 generation pedigree charting along with recording of clinical and investigational parameters.
Results: Systemic AID was seen in 39 families with a point- prevalence of 24.8% (95% CI 18.1, 31.6) and aggregation relative risk (RR) of Î"-2.48. Family history of SLE was seen in 19 families with a point- prevalence of 12.1% (95% CI 7.0, 17.2) and Î"-2. Both AID as a whole and lupus alone were seen more commonly with parental consanguinity (p<0.05) with no specific inheritance pattern. AID including lupus was seen commonly in 1st degree (64.1% and 63.15% respectively) followed by 2nd degree relatives (43.5% and 52.6%). Most prevalent co-existent organ-specific AID was auto-immune thyroid disease (AITD) seen in 42 (26.75%) families, which also co-existed in 27 (17.2%) lupus pro-bands. Familial aggregation in lupus pro-bands showed relatively higher percentage of affected males and lesser constitutional features than sporadic pro-bands (p<0.05), otherwise there were similar clinical features and serological parameters between sporadic and lupus probands.
Conclusion: In Asian Indian lupus pro-bands, familial aggregation of rheumatic AID and Lupus alone was noted in 24.8% (RR-2.48) and 12.1% (RR-2) respectively, more so in the background of parental consanguinity.
OC016 Paediatric Rheumatology
Prospective validation of the juvenile spondyloarthritis disease activity index and its comparison with adult spondyloarthritis disease activity scores
Abhishek Zanwar, Sanat Phatak, Amita Aggarwal; Department of Clinical Immunology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Background: Among JIA children with Enthesitis related arthritis (ERA) category have more pain, poorer health status and are less likely to achieve or maintain sustained remission. Recently the Juvenile Spondyloarthritis Disease Activity Index (JSpADA) was developed. We planned to prospectively validate JSpADA and compare its performance with other disease activity scores used in children and adults.
Methods: Children with ERA (ILAR criteria) less than 18 years of age were enrolled. Baseline characteristics and different disease activity measures were recorded at baseline and on follow up after at least 3 months of follow up. At both visits physician global assessment and patient global assessment was recorded on the scale of 0-10.
Results: The mean age of 125 children (114 boys) was 14.2 + 2.23 years. The mean disease duration was 34.8 + 28.04 months. 89 children had persistent disease while 31 had episodic disease and 5 children had less than 3 months of disease. 86% children were HLA-B27 positive. 61.6% children had inflammatory back pain ever and 43% had radiographic sacroiliitis. 113 had peripheral arthritis ever (90.4%). Among 125 patients 91 were taking NSAIDs and 28 were taking synthetic DMARDs. Mean disease activity score were, JSpDA: 3.07 + 1.84, JADAS10: 12.43 + 8.58, BASDAI: 3.06 + 2.3 ASDAS ESR: 3.01 + 1.24. Mean C-HAQ was 0.75 + 0.65. JSpDA showed high correlation with JADAS-10 (r=0.874) and PGA (r= 0.875), moderate to high correlation with C-HAQ (r=0.733). Hence demonstrated good construct validity. Correlation between peripheral disease component and total score was 0.96, showing good internal consistency. The mean JSpDA scores for children with a physician global assessment (PGA) on visual analog scale score of 0 (n =19) and >0 (n=105) were 0.31 and 3.6 respectively (p< 0.001) hence showing good discriminative validity. 37 children had a follow up visit; disease activity increased in 21, decreased in 13 and did not change in 3. Mean change in JSpDA was significantly different among those who improved [+2.29+0.57] when compared to who worsened [-1.67 + 0.48; (p<0.001)], showing good sensitivity to change. JSpDA also showed highly correlation with other scores like JADAS10 (r=0.87) and BASDAI(r=0.83), ASDAS ESR(r=0.85).
Conclusion: JSpADA is a valid score for measuring disease activity in ERA.
OC017 Paediatric Rheumatology
Cluster analysis and clinical associations of autoantibodies in pediatric systemic lupus erythematosus: A single center cohort study
S Kumar, S Prasad*, V Jeyaseelan1; Departments of Pediatrics and 1Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
Introduction: The serological hallmark of systemic lupus erythematosus (SLE) is the presence of autoantibodies directed against multiple nuclear and cytoplasmic antigens and phospholipid components of cell membranes. Some of these autoantibodies are useful for classification purposes and are part of the American College of Rheumatology classification criteria for SLE and associated with specific clinical features. Studies in SLE have reported a tendency of these autoantibodies to occur in pairs or even in clusters, which has led to description of new clinical associations in adult onset SLE. To date, there have been few studies of autoantibody associations with clinical disease in pediatric-onset SLE.
Objectives: 1) To evaluate the spectrum of serum autoantibodies in pediatric-onset systemic lupus erythematosus using cluster analysis and (2) To identify patients with similar autoantibody patterns and to determine their clinical associations using cluster analysis
Methods: A single center retrospective cohort study of all newly diagnosed pSLE seen over a 6 year period was performed. Clinical manifestations and autoantibody tests which were done at time of presentation were collected. Cluster analysis identified groups of patients with similar autoantibody profiles. Associations of these groups with clinical and laboratory features of pSLE were examined.
Results: Cluster analysis was done for all 212 patients and we divided them into five major clusters. But in Akaike's information criteria (AIC), we have identified that only 3cluster group analysis can be done to get better results [Figure 1]. Cluster 1 consisted of ANA and anti-dsDNA antibodies. Cluster 2 consisted of anti-dsDNA, ANA, anti-RNP, anti-Sm autoantibody. Cluster 3 consisted of antidsDNA, ANA, anti-SSA, and anti-cardiolipin autoantibody. Cluster 1was characterized to have major organ involvement with increased frequency of renal, neurological and haematological manifestations. Cluster 2 was characterised by arthritis and increased frequency of raynauds phenomenon. Cluster 3 tended to have milder symptoms with more frequently having hairloss, photosensitivity and serositis.[INLINE:7]
Conclusion: Autoantibodies in pSLE tended to cluster together and these clusters were associated with different clinical courses. From the clinical perspective, this finding suggests that determining the complete autoantibody profile may help predict the clinical course of pSLE and identify patients at risk of developing major organ involvement.
OC018 Miscellaneous Rheumatic and Inflammatory Disease
A randomized alendronate-controlled trial of romosozumab: results of the phase 3 arch study (active-controlled fracture study in postmenopausal women with osteoporosis at high risk)
Kenneth G Saag, Jeffrey Petersen1, Maria Luisa Brandi2, Andrew Karaplis3, Mattias Lorentzon4, Thierry Thomas5, Judy Maddox1, Michelle Fan1, Paul Meisner6, Andreas Grauer1; University of Alabama, Birmingham, AL, 1Amgen Inc., Thousand Oaks, CA, USA, 2University of Florence, Florence, Italy, 3McGill University, Montreal, QC, Canada, 4University of Gothenburg and Sahlgrenska University Hospital, MÃlndal, Sweden, 5CHU de Saint-Étienne, Saint-Étienne, France, 6UCB Pharma, Brussels, Belgium
Background: The bone forming agent romosozumab was previously shown to reduce vertebral and clinical fractures in postmenopausal women with osteoporosis.
Objective: To report the results of the ARCH study (NCT01631214).
Methods: This multicenter double-blind study enrolled postmenopausal women age 55-90 years with osteoporosis and high fracture risk, defined as a BMD T-score ≤-2.5 at total hip (TH) or femoral neck (FN) and either ≥1 moderate/severe or ≥2 mild vertebral fractures, or a BMD T-score ≤-2.0 at TH or FN and either ≥2 moderate/severe vertebral fractures or a history of a recent hip fracture. Subjects were randomized 1:1 to 210mg romosozumab subcutaneously monthly or 70 mg alendronate orally weekly for 12 months, followed by open-label 70 mg alendronate orally weekly in both groups. Primary endpoints were incidence of new vertebral fracture through 24 months and clinical fracture at primary analysis (event-driven upon ≥330 clinical fractures). Secondary endpoints included incidences of nonvertebral and hip fracture at primary analysis.
Results: 4093 women (mean age 74, mean TH T-score -2.8) were randomized to romosozumab or alendronate. Twelve months of romosozumab prior to alendronate versus alendronate alone significantly reduced new vertebral, clinical, nonvertebral, and hip fractures [Table 1]. Romosozumab-to-alendronate treatment also significantly increased BMD at all sites measured, at months 12 and 24 versus alendronate-to-alendronate [Table 1]. Overall adverse events were balanced between groups. During the open-label alendronate period, 6 subjects (2 romosozumab-to-alendronate; 4 alendronate-to-alendronate) were positively adjudicated for AFF and 2 subjects (1 romosozumab-to-alendronate; 1 alendronate-to-alendronate) for ONJ. Cardiovascular serious adverse events (SAEs) were independently adjudicated; at 12 months the incidence was 2.5% in the romosozumab-to-alendronate group versus 1.9% in the alendronate-to-alendronate group with cardiac ischemic events at 0.8% versus 0.3% and cerebrovascular events at 0.8% versus 0.3%, respectively.[INLINE:8]
Conclusions: In postmenopausal women with osteoporosis, romosozumab 210 mg monthly followed by alendronate significantly reduced fracture risk versus alendronate-to-alendronate, suggesting that in osteoporotic patients at high risk for fracture, a treatment regimen starting with romosozumab followed by alendronate leads to superior fracture risk reduction over alendronate alone. An imbalance in cardiovascular SAEs compared with alendronate, not seen in the previous placebo-controlled 7180-patient FRAME study, is being evaluated.
Higher disease activity at baseline predicts progression of damage in Takayasu arteritis
A Jain, A Zanwar, D P Misra, R Misra, P A Bacon1; Department of Clinical Immunology, SGPGIMS, Lucknow, Uttar Pradesh, 1Department of Rheumatology, University of Birmingham, Birmingham, UK
Introduction: Takayasu's arteritis (TA), a chronic large vessel vasculitis, continues to pose difficulties from delay in diagnosis to assessment of disease activity, prediction of disease course and need for treatment.
Objective: Assess progression of disease using Takayasu arteritis damage score (TADS) and its relationship with clinical parameters, including disease extent assessed using Disease extent index in TA (DEI.Tak) and disease activity using Indian Takayasu's Clinical Activity Score (ITAS2010 and ITAS.A) at baseline.
Methods: 49 patients of TA, diagnosed by ACR 1990 criteria, with a minimum follow-up duration of one year, were retrospectively analysed. Their clinical characteristics, angiographic classification, DEI.Tak, ITAS2010 and treatment details were recorded. Damage was defined using TADS (including features present for ≥ six months). Progression was defined as change in TADS by ≥1, thereby categorizing the cohort into progressors or non-progressors. Pulse loss, bruit which are to be scored in ITAS at first visit as per definition, were scored as damage and not activity.
Results: We analysed 49 patients with a median follow up duration of 1.9 years. Table 1 sums up their clinical features and differences between progressors and non-progressors. 20/49 patients showed progression with mean change in TADS, after a median follow up of 1.9 years, by 3.3 ± 2.3. ITAS2010 and ITAS A scored at baseline were 3.6 ± 2.8 and 5 ± 3.0 respectively. This was significantly high when compared to 29 non progressors as defined by TADS after a median follow up of 1.9 years. Their ITAS2010 and ITAS A score were 1.7 ± 1.8 and 3.4 ± 2.2 respectively with a p value of 0.0057 and 0.0363. There was no difference in the proportion of patients on DMARDs in either group.[INLINE:9]
Conclusion: Modified ITAS and ITAS A score could serve as a guide to define group of patients who may progress and would help in optimising therapy for these patients. However being a retrospective analysis of a small cohort of patients is one of the limitation and it may be worthwhile to prospectively look at disease progression and its relationship with baseline ITAS2010 with or without treatment.
Evaluation of the predictive validity of the asas axial spondyloarthritis criteria in the DESIR cohort
B Meghnathi*, A Etcheto, A Saraux1, M Dougados, A Molto1; Department Rheumatology B, Medicine Faculty, Paris Descartes University, APHP, Cochin Hospital, Paris, 1La Cavale Blanche Hospital, Rheumatology and Universite de Bretagne Occidentale, Brest, France
Background: The face and external validity of the Assessment of SpondyloArthritis international Society (ASAS) criteria and its arms for axial spondyloarthritis (axSpA) has been confirmed. However, so far, only one study has reported data regarding the predictive validity of such criteria.
Objectives: To evaluate the predictive validity of 1) ASAS criteria and its arms, 2) Other SpA criteria sets - Amor, ESSG and mNY, after 5 years of follow-up.
Methods: This analysis was performed on the DESIR cohort. A total of 708 adult (>18 and <50 years) patients presented with inflammatory back pain suggestive of axSpA (according to the rheumatologistâ€™s conviction of â‰¥ 5/10) for >3 months but <3 years duration, were followed up every 6 months for first 2 years and then yearly up to 5 years. Gold standard for this analysis was diagnosis of axSpA according to rheumatologist at 5 years of follow-up. For this analysis, patients were considered as axSpA, if the rheumatologist, at 5 years had conviction of â‰¥7/10 for an axSpA diagnosis. Conversely, patients excluded as per protocol due to another diagnosis or patients with a rheumatologist conviction at 5 years of â‰¤3/10 for axSpA were considered as Non-axSpA. The set of criteria collected at baseline (ASAS, and its arms, Amor, ESSG and mNY: fulfilled/not fulfilled) were tested against the Rheumatologistâ€™s axSpA diagnosis (fulfilled/not fulfilled) after 5 years of follow-up. Predictive validity of all sets of criteria at baseline was evaluated by the positive predictive value.
Results: In total, among the 708 patients included in the DESIR cohort at baseline, data on Rheumatologists diagnosis at 5 years was available in 454 patients; amongst them, 352 (77.5%) had an axSpA diagnosis according to the rheumatologist. Among these 352 patients, 245, 300, 291 and 88 patients fulfilled the ASAS criteria for axSpA, Amor, ESSG and modified NY criteriaâ€™s respectively. [Figure 1] shows the PPV (95% CI) of the different sets of criteria below.[INLINE:10]
Conclusions: Predictive validity of the ASAS criteria for axSpA (including both arms) at 5 years was excellent; it is worth noting that performances of other criteria's was also very good.
Ultrasonographic and clinical evaluation of peripheral enthesitis in Indian spondyloarthritis patients
Saumya Ranjan Tripathy, Archana Wakhlu*, Puneet Kumar, Urmila Dhakad, Anupam Wakhlu; Departments of Rheumatology and *Radiodiagnosis, King George's Medical University, Lucknow, Uttar Pradesh, India
Background: Enthesitis is an important clinical manifestation of spondyloarthritis (SpA). Ultrasonography (USG) is an emerging tool for detecting enthesitis. Data on USG-detected enthesitis in spondyloarthritis from India is limited.
Objectives: To determine -a) prevalence of enthesitis in spondyloarthritis; b) correlation between ultrasonography and clinical examination for detecting enthesitis; c) USG-score for detecting SpA-specific enthesitis.
Methods: Patients (n=100) satisfying ASAS criteria for axial and/or peripheral SpA were recruited. Age and sex matched 50 healthy individuals without family history of SpA and 50 rheumatoid arthritis (RA) patients were recruited as controls. USG was done with B-mode settings: dynamic range (40-50dB); GS-frequency (11-13 MHz); GS-gain (60dB). Power Doppler (PD)-mode settings used: pulsed repetition frequency (400-800Hz); PD-gain (highest possible gain with minimum background noise). The following entheseal sites were screened: bilateral plantar fascia on calcaneus (PF), Achilles tendon at calcaneus, quadriceps tendon on patella (QT) and patellar tendons proximally on patella (PTprox) and distally on tibia (PTdistal). USG parameters included detection of erosion/hypoechogenicity/enthesophytes/increased thickness/intratendinous calcification on Grafy-scale and presence of PD-signals as per OMERACT-2014 guidelines (Terslev et al). Power Doppler was graded on a scale of 0-3(Kiris et al, 2006). USG-score was calculated by adding 1 point for each Gray-scale finding and the grade of PD-signal at each site. Clinical enthesitis score was calculated by adding 1 point for each positive site on clinical examination at entheseal sites included in MASES and additionally at PF, QT, PTprox and PTdistal bilaterally.
Results: USG was more sensitive than clinical examination for detection of enthesitis in SpA patients (96% versus 71% respectively; p<0.01). PD-signals were positive at 154 sites (15.4%) in SpA, 2 sites in RA (0.4%) and none in healthy individuals. The mean USG-score in SpA was 7.77 ± 4.67 (1 SD) while the maximum USG-score in non-SpA patients was 3. Defining USG-score for SpA -specific enthesitis as -a) USG-score≥4 or b) USG-score≥1 and PD-score≥1; and assuming all SpA patients have enthesitis, the sensitivity and specificity of USG was 87% and 98% respectively versus clinical examination (77% and 100% respectively). USG-score correlated with clinical enthesitis score (r=0.37; p<0.01).
Conclusion: Ultrasonography including Power Doppler has higher sensitivity than clinical examination for detection of enthesitis. USG correlates with clinical examination for detection of enthesitis.
OC022 Scleroderma, Myositis and Overlap
A randomized controlled, open label trial of cyclophosphamide versus rituximab in diffuse systemic sclerosis
Geetabali Sircar, Rudra Prasad Goswami, Deepak Rath, Avishek Naskar, Hiramani Sit, Subhankar Haldar, Pradyot Sinhamahapatra, Alakendu Ghosh, Parasar Ghosh; Department of Rheumatology, IPGMER, Kolkata, West Bengal, India
Introduction: Cyclophosphamide has been the mainstay of therapy in scleroderma, with improvements shown in pulmonary function tests. B cell depletion therapy in systemic sclerosis has been shown to be efficacious in lung involvement as well.
Objective: To compare the safety and efficacy of rituximab (RTX) to cyclophosphamide (CYC) in the treatment of diffuse systemic sclerosis (dSSc) with reference to lung and skin manifestations.
Subjects and Methods: This study is an open label, prospective randomized, controlled trial with a 1:1 allocation of patients in 6 monthly cyclophosphamide 600mg per m2 or 1 gm Rituximab at 0 and 2 weeks, along with 10 mg prednisolone for 6 months. Outcomes in the two groups were analyzed after the completion of six months. 60 adult patients of dSSc, who fulfilled ACR criteria with disease duration 3 years or less with ILD, and who did not receive CYC, RTX, mycophenolate or azathioprine previously were randomly assigned to either of the regimens.
Results: Sixty patients received either RTX (N=30) or CYC (n=30). The FVC, six min walk test and modified Rodnan skin score improved from baseline to 6 months by +6.22% (RTX) vs, -1.18%(CYC), +58 feet vs +49 feet (p=0.01) and -9.7 vs -5.5 (p=0.02) respectively. However, the Medsger score did not differ -3.4 vs -3.3 (p=0.861). One patient had two episodes of severe respiratory infection and two patients had premature ovarian failure in CYC group but none in RTX group.
Conclusion: Six months therapy with RTX resulted in significant improvement in lung function and skin tightening as compared to CYC. There were more major adverse events in cyclophosphamide group.
OC023 Scleroderma, Myositis and Overlap
Correlation of nailfold capillaroscopy parameters with organ involvement in patients with systemic sclerosis: A cross-sectional study
Isha Sood, Nikunjkumar V Dadhaniya, Sundeep Upadhyaya, Sirinder J Gupta, Rohini Handa; Department of Rheumatology, Indraprastha Apollo Hospitals, Delhi, India
Objective: Nailfold capillaroscopy is used in systemic sclerosis for both diagnostic and prognostic purposes. This study was undertaken to find the correlation of capillary density (CD), enlarged capillaries (EC) [Figure 1] and number of haemorrhages (NH) and vascular deletion score (DS) with various clinical parameters.[INLINE:11]
Methods: 47 patients with SSc (27 limited (LcSS) and 20 diffuse (DcSS) systemic sclerosis) with age range 23-72 yrs, who fulfilled 2013 classification criteria for SSc were included in the study. The middle 3 mm periungual region of eight fingers were studied (excluding thumb) on both hands. Also, the capillary density (CD), enlarged capillaries (EC) and the number of haemorrhages (NH) and vascular deletion score (DS) were evaluated. The correlation of Skin thickness (assessed by MRSS), Pulmonary arterial hypertension (PAH), Interstitial lung disease (ILD), Finger to palm distance (FTP), presence of digital pits, haemoglobin levels (Hb) and GFR with Capillaroscopic parameters was calculated using Pearson's correlation and Mann-Whitney tests was used to compare quantitative variables. p <0.05 was considered significant.
Results: Mean MRSS was 19.3Â± 13.5. A statistically significant difference (P= 0.005) in mean CD between, LcSS (5.7 Â±2.03) and DcSS (3.05Â±0.89) was found. Significant inverse correlation was found between MRSS and Capillary density (CD) (r = -0.56, P< 0.05), FTP and CD (r = -0.45, P = 0.01) and Hb and DS (r = -0.28, P <0.05). Significant positive correlation was found between MRSS and DS (r = 0.65, P =0.00018). Patients with PAH on echocardiography (14 pts) were found to have significantly reduced capillary density (P =0.008) and higher DS (P= 0.01) while no significant correlation was found with ILD. CD in Scl 70 positive patients was lower (3.9Â±2.9) as compared to pts who were Scl-70 neg (5.7Â±2.8, P<0.04). The mean GFR was 89 Â± 39.26. There was a significant inverse correlation of GFR with NH (r = -0.292, P<0.05) and GFR with EC (r = -0.39, P <0.05).
Conclusion: In SSc a reduction of capillary density is associated with the presence of Anaemia and PAH and but not ILD. An increase in the number of enlarged capillaries and presence of haemorrhages is associated with decline in GFR.
Long term outcome of tocilizumab therapy for management of Takayasu arteritis
Ruchika Goel, G Salil, Debashish Danda; Department of Clinical Immunology and Rheumatology, CMC, Vellore, Tamil Nadu, India
Background: Tocilizumab is an Interleukin-6 receptor blocker. Previous studies have shown its efficacy in management of refractory Takayasu arteritis (TA). Data regarding its long term results after discontinuation of tocilizumab and maintenance with other immunosuppressants is sparse.
Objectives: We aimed to study long term efficacy of tocilizumab in our cohort of TA.
Methods: Patients satisfying 1990 ACR criteria for TA, who had been initiated on tocilizumab were followed up. Data regarding indication of therapy, disease activity, laboratory parameters and adverse events was recorded prospectively. Disease acitivty was defined by a composite tool comprising of ITAS-2010, C-reactive protein and imaging findings if performed. The results were analysed descriptively.
Results: Altogether, 44 patients received tocilizumab in our series of which 14 were given at initial visit while 30 patients received it as rescue therapy for relapses or lack of response to conventional therapy. Indications were active disease or new vascular involvement in 31, to obtain good results after revascularization of critical arteries in 2 and while to maintain stent patency in 11 patients experiencing repeated in-stent restenosis Response to tocilizumab: Of 31 patients receiving tocilizumab for active disease immediate response was assessed in 25 patients and not assessed in 6 patients due to delayed or no follow up. Complete/partial response was observed in 68% patients with refractory/relapsing disease. 61% of patients who received tocilizumab to improve revascularisation procedure outcome responded. In complete responders, steroid dose decreased from 25 (10-35) mg/d during first infusion to 7.5 (5-11.2) mg/d at last infusion. Time to response was 1 (1-3.25) month and ITAS was 0 in all responders during last infusion. During 16.5 (9.5 to 31) months after withdrawal of tocilizumab, sustained complete and partial response was observed in 7 and 3 patients respectively while 7 had relapse of disease activity. Time to relapse was 4.5 (1.8- 9.0) months. Seven of 11 patients with repeated in-stent stenosis maintained patent stents during tocilizumab therapy and the efficacy was sustained in 6 of them even of its discontinuation.
Conclusion: Tocilizumab was efficacious both as short term and long term immunosuppressive therapy in majority of our TA patients.