Search

BackgroundJuvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children1. Our group has recently demonstrated that extended oligoarticular (eoJIA) and polyarticular JIA (pJIA) mostly evolve to a rheumatoid arthritis (RA) like phenotype in adulthood2. Disturbances in B cells, T follicular helper (Tfh) and T follicular regulatory (Tfr) cell immune responses are associated with the pathogenesis of RA3,4, but their exact role in JIA development is not entirely known.ObjectivesThe main goal of this study was to characterize the frequency and phenotype of B, Tfh and Tfr cells in peripheral blood of children with eoJIA and pJIA when compared to healthy controls and children with persistent oligoarticular JIA (poJIA).MethodsBlood samples were collected from children with eoJIA (n=5), pJIA (n=11) and poJIA (n=19) treated with disease modifying anti-rheumatic drugs. A group of age-matched healthy individuals (n=8) was used as control. Peripheral blood mononuclear cells were isolated and the frequency and phenotype of B, Tfh and Tfr cells were evaluated by flow cytometry.ResultsThe frequency of B, Tfh and Tfr cells was similar between JIA patients and controls. Children with eoJIA and pJIA, but not poJIA, had higher levels of naïve B cells and lower frequencies of post-switch memory B cells and plasmablasts when compared to controls. Th17-like Tfh cells were significantly increased in all JIA patients when compared to controls. B cell phenotype was similar between JIA patients and controls, but a reduced activated phenotype of Tfh cells was observed in JIA patients in comparison to controls.ConclusionChanges in B and Tfh cell subpopulations, but not in Tfr cells, were found in peripheral blood of children with JIA when compared to controls. The increased frequencies of Th17-like Tfh cells detected in JIA when compared to controls suggests a potential role of these cells in JIA pathogenesis. A treatment effect on the activation state of B, Tfh and Tfr cells cannot be excluded.References[1]Ravelli, A. & Martini, A. Juvenile Idiopathic Arthritis. Lancet 369, 767–778 (2007).[2]Oliveira-ramos, F. et al. Juvenile idiopathic arthritis in adulthood: fulfillment of classification criteria for adult rheumatic diseases, long-term outcomes and predictors of inactive disease, functional status and damage. 1–10 (2016)[3]Moura, R. A., Graca, L. & Fonseca, J. E. To B or not to B the conductor of rheumatoid arthritis orchestra. Clin. Rev. Allergy Immunol. 43, 281–291 (2012).[4]Deng, J., Wei, Y., Fonseca, V. R., Graca, L. & Yu, D. T follicular helper cells and T follicular regulatory cells in rheumatic diseases. Nat. Rev. Rheumatol. 15, 475–490 (2019).AcknowledgementsC. Tomé was supported by a fellowship from Fundação para a Ciência e a Tecnologia (FCT) (PD/BD/135520/2018), Portugal. This work was supported by a grant from Sociedade Portuguesa de Reumatologia.Disclosure of InterestsNone declared.

Background:Lupus nephritis (LN) is one of the most severe manifestations of Systemic Lupus Erythematosus.Objectives:1) To compare proliferative (PLN), membranous (MLN) and mixed LN regarding clinical and laboratory presentation. 2) To investigate predictors of progression to chronic kidney disease (CKD).Methods:Multicentre observational study, with retrospective analysis of a prospective cohort, using data from the Portuguese registry of rheumatic diseases – Reuma.pt. Patients with biopsy-proven PLN, MLN and mixed LN were included. Groups were compared using Pearson’s Chi-Square for categorical variables and One-Way ANOVA or Kruskal-Wallis for numerical variables. COX regression analysis was used to investigate predictors of CKD (defined as estimated glomerular filtration rate [eGFR] lower than 60 mL/min/1.73m2for at least 3 months) and Kaplan-Meier curves were drawn.Results:236 patients were included. Median follow-up was 8 years (IQR 11; maximum 35 years). As seen in table 1, the level of proteinuria did not differ between groups; however, MLN patients presented with significantly lower serum creatinine. Levels of complement C3 and C4 were reduced in PLN but normal in MLN patients, and there were fewer patients with positive anti-dsDNA antibodies in the MLN group (pTable 1.Comparative description of the Reuma.pt cohort of patients with proliferative, membranous and mixed LNPLNMLNMixedPTotal, N186428Females, N (%)157 (85)39 (95)4 (50)0.004EthnicityWhite European, N (%)163 (90)31 (78)7 (88)0.115Other, N (%)19 (10)9 (23)1 (13)Age LN diagnosis(y), median (IQR)30 (20)34 (16)42 (25)0.409SLEDAI at LN diagnosis, median (IQR)16 (9)10 (10)21 (17)0.006*uPCR at LN diagnosis, median (IQR)1675 (2598)1698 (2153)2160 (3320)0.629Creatinine at LN diagnosis, median (IQR)0.80 (0.32)0.70 (0.20)1.00 (0.95)0.006*eGFR at LN diagnosis, mean ± SD98 ± 33112 ± 1782 ± 450.019*Albumin at LN diagnosis, mean ± SD34 ± 734 ± 730 ± 60.390C3 at LN diagnosis, mean ± SD0.65 ± 0.260.90 ± 0.350.53 ± 0.30Positive anti-dsDNA LN diagnosis, N (%)115 (91)11 (48)6 (86)Use of antimalarials, N (%)166 (94)36 (92)8 (100)0.688Use of immunosuppressants, N (%)163 (94)33 (87)8 (100)0.245Use of corticosteroids, N (%)145 (84)33 (85)7 (100)0.511CKD after LN diagnosis, N (%)27 (15)1 (3)3 (38)0.018*ESRD, N (%)7 (4)1 (3)2 (25)0.016Deaths, N (%)14 (8)2 (5)00.610uPCR: urinary protein-creatinine ratio, mg/g; y: years; Creatinine presented in mg/dL, eGFR in mL/min/1.73m2,albumin in g/L and C3 in g/LNote: Baseline data (LN diagnosis) in grey; other data refer to the course of disease*Significant difference between the proliferative and membranous groupsFigure 1.Kaplan-Meir curves showing cumulative survival free of CKD in patients with PLN, MLN and mixed LNConclusion:Our results support previous findings from single-centre studies suggesting that MLN has a different serological profile than PLN, possibly reflecting different pathogenesis. Renal function at one year predicts long-term outcome in LN.Disclosure of Interests:Filipa Farinha: None declared, Sofia C Barreira: None declared, Maura Couto: None declared, Margarida Cunha: None declared, Diogo Fonseca: None declared, Raquel Freitas: None declared, Luís Inês: None declared, Mariana Luis: None declared, Carla Macieira: None declared, Ana Rita Prata: None declared, Joana Rodrigues: None declared, Bernardo Santos: None declared, Rita Pinheiro Torres: None declared, Ruth J. Pepper: None declared, Anisur Rahman: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer

Background:Methotrexate (MTX) is an anti-folate drug with anti-proliferative and anti-inflammatory effects. MTX proved to be the most highly effective, fast-acting disease modifying anti-rheumatic drug (DMARD), being widely used for the treatment of rheumatoid arthritis (RA) (1).Objectives:This review aims to describe the main genetic variants identified concerning proteins that play a role in methotrexate’s kinetics and efficiency profile.Methods:A literature review was conducted since January of 2000 until December 2020, by searching the PubMed and Embase bibliographic databases, employing the following MeSH terms: methotrexate, pharmacogenetics, pharmacokinetics and rheumatoid arthritis. The search was limited to articles in English language. Two independent reviewers screened the titles and abstracts followed by a full-text review to assess papers regarding their eligibility. A total of 48 articles matched the research criteria and were analysed.Results:Genetic variants of four main proteins, with different functions, have been consistently described.Reduced folate carrier 1 (RFC1), a constitutively expressed folate transport protein that has high affinity for MTX is responsible, almost exclusively, for the transport of folate and MTX into the cell. The most commonly studied variant of the gene is the 80G > A variant (rs1051266), mapped within exon 2, on chromosome 21. It seems to improve RA responses to MTX, clinical efficacy with long disease remission (2).ABC transporters are involved in the eflux of MTX from cells. An increased expression and function of these transporters should decrease MTX concentrations in target cells, resulting in lack of therapeutic response. ABCB1 3435 C/T (rs1045642) is a high frequency polymorphism, significantly associated with RA good responses, symptom remission and reduced adverse events, due to MTX treatment (3).Thymidylate synthase (TYMS) is involved in thymidine synthesis. MTX decreases TYMS activity by inhibition and decreasing the access to tetrahydrofolate (THF) cofactors (1). The most common genetic variant of the TYMS gene consists of a 28 bp tandem repeat (rs34743033), with double and triple number of repeats (2R and 3R). The 3R allele genotype was associated with decreased efficacy and increased toxicity (4).The 5,10-methylenetetrahydrofolate reductase (MTHFR) enzyme is indirectly inhibited by MTX. The most common SNPs of the MTHFR gene are C677T (rs1801133) and A1298C (rs1801131). Both are associated with a decreased efficacy and an increased toxicity of MTX (5).Conclusion:MTX response is affected by many gene variants; the effect of each variant separately is likely to be small. Additionally, gene-gene interaction, enhancing the potential role of linkage disequilibrium. This shows the emerging need for a better gene characterization and to improve the knowledge about variants distribution according to ethnicity, to explain different responses to MTX at an individual level.References:[1]Song, G. et al. Association of the MTHFR C677T and A1298C polymorphisms with methotrexate toxicity in rheumatoid arthritis: a meta-analysis. Clin Rheumatol33, 1715–1724 (2014).[2]Hayashi H. et al. A single nucleotide polymorphism of reduced folate carrier 1 predicts methotrexate efficacy in Japanese patients with rheumatoid arthritis. Drug Metab Pharmacokinet. 2013;28(2):164-8.[3]Zhu H. et al. Pharmacogenetics and pharmacogenomics for rheumatoid arthritis responsiveness to methotrexate treatment: the 2013 update. Pharmacogenomics. 2014 Mar;15(4):551-66.[4]Owen SA. et al. Genetic polymorphisms in key methotrexate pathway genes are associated with response to treatment in rheumatoid arthritis patients. Pharm J. 2013;13:227–34.[5]Hughes LB. et al. Racial or ethnic differences in allele frequencies of single-nucleotide polymorphisms in the methylenetetrahydrofolate reductase gene and their influence on response to methotrexate in rheumatoid arthritis. Ann Rheum Dis. 2006;65:1213–8.Disclosure of Interests:None declared

Background:Enthesitis is a recognized as a hallmark of spondyloarthrtis (SpA), including psoriatic arthritis (PsA). However, it is an underestimated disease domain in both in clinical trials and clinical practice (1).Objectives:This systematic literature review (SLR) assessed the efficacy of the available pharmacological options for enthesitis.Methods:A SLR was conducted following the PRISMA reporting guidelines. Studies were sourced from PubMed and Embase databases, using the MeSH terms: enthesitis, entheses, treatment, spondylarthritis, ankylosing spondylitis and psoriatic arthritis. The search was limited to articles in English published between January 2000 and July 2020. Two independent reviewers screened the titles and abstracts.Results:A total of 65 articles matched the research criteria. The included populations, the time to assessment of the primary endpoint and the chosen outcome for assessment of enthesitis was heterogeneous across studies. There were no studies assessing the effect of non-steroidal anti-inflammatory drugs, glucocorticoids, or csDMARDs. In PsA, all TNFis showed superiority in monotherapy against placebo (PBO). However, when combined with methotrexate (MTX), only some TNFi showed superiority against MTX monotherapy. In SpA, there was conflicting evidence regarding the efficacy of TNFi in enthesitis. Regarding IL23i in PsA, Ustekinumab was superior to PBO, and to TNFis. Guselkumab was superior to PBO when given every 4 weeks. Regarding IL7i, Secukinumab (SEC) was superior to PBO, only for some dosing schemes. Ixekizumab (IXE) was superior to PBO for the treatment of enthesitis only in TNF-naïve patients. Studies comparing SEC and IXE to ADA, showed no difference. There was no reported data on IL17i for enthesitis in SpA. In PsA, Tofacitinib was superior to PBO in naïve patients, and Tofacitinib 10mg was superior to PBO in bioexperienced patients. Apresmilast 30mg showed superiority to PBO for enthesitis. All finding are summarized on Table 1.Table 1.Findings of the systematic literature review on treatment options for enthesitisDiseaseTested drug vs ReferenceSuperiority of the treatment arm against reference arm (p)ReferencePsATNFi vs PBOYESNCT00051623 (IFX)NCT00265096 (GOL)NCT01087788 (CZP)TNFi+MTX vs PBO+MTX(PBO+ETN one study) vs PBO+MTXNONCT00367237 (IFX)NCT02065713 (GOL)NCT02376790 (ETN)UST vs PBOYESNCT01009086NCT01077362UST vs TNFiYESEudraCT 2017-003799-29 βGUS q4w vs PBOGUS q8w vs PBOYESNONCT03162796NCT03158285SEC (pooled dose) vs PBOYESNCT01392326NCT01752634SEC 300mg vs PBOSEC 150mg vs PBOYESNONCT01989468SEC 300mg with loading vs PBOSEC 150mg with loading vs PBOSEC 150mg no loading vs PBOYESYESNONCT02404350IXE vs PBOADA vs PBOYESNOPsA BionaiveNCT01695239IXE vs PBONOPsA BioexperiencedNCT02349295IL17i (SEC/ ADA) vs TNFiNONCT02745080 (SEC)NCT03151551 (ADA) βAPR 20mg vs PBOAPR 30mg vs PBONOYESNCT01172938TOF 5mg vs PBOTOF 10mg vs PBOADA 40mg vs PBONOYESNONCT01877668 (TNFi-naive)TOF vs PBONONCT01882439 (TNFi-failure)SpAETN vs SSZYES (imaging)/ NO (clinical)axSpANCT00844142ETN vs PBOYES for nr-axSpANCT01258738ADA vs PBOYES for r-axSpANO for nr-axSpAYES for perSpANCT00195819NCT00939003NCT01064856GOL IV vs PBOYES for r-axSpANCT02186873GOL 100mg vs PBOGOL 50mg vs PBOYESNOFor r-axSpANCT00265083GOL vs PBOYES nr-axSpANCT01453725β-Open-label; PsA: Psoriatic arthritis; r-axSpA: Radiologic axial spondylarthritis; nr-axialSpA: non radiological axial spondylarthritis; PBO: Placebo; TNFi: Tumor necrosis factor inhibitors; ETN: Etanercept; IFX: Infliximab; ADA: Adalimumab; GOL: Golimumab; UST: Ustekinumab; CZP: Certolizmab; GUS: Guselkumab; SEC: Secukinumab; IXE: Ixekizumab; APR: Apremilast; TOF: Tofacitinib; MTX - MethotrexateConclusion:This SLR emphasizes the current heterogeneity in the assessment and report of enthesitis. There is still an unmet need for further studies to improve our understanding about enthesopathy.References:[1]Schett G. et al. Enthesitis: from pathophysiology to treatment. Nat Rev Rheumatol. 2017;13(12):731-41.Disclosure of Interests:Rita Pinheiro Torres: None declared., Santiago Rodrigues-Manica Speakers bureau: Novartis, Janssen and MSD, Fernando Pimentel dos Santos: None declared.

Background:Juvenile idiopathic arthritis (JIA), one of the most common chronic diseases in children, can be classified in seven different categories according to its onset presentation. Concerns about pregnancy outcomes play a secondary role in disease approach. However, recent data showed an increased risk of pre-term birth in women with JIA instead the small patient samples analysed.Objectives:In this review, our aim is to describe the current available knowledge on JIA adverse, maternal and fetal, outcomes.Methods:A systematic literature review was conducted since January of 2000 until December 2020, by searching the PubMed and Embase bibliographic databases. The search was limited to articles in English language, presenting a comparator group (healthy individuals or patients without known auto-immune rheumatic diseases) and at least one clinical outcome of interest. Two independent reviewers screened the titles and abstracts followed by a full-text review to assess papers regarding their eligibility.Results:Ten observational studies out of 1560 references, fulfilled the inclusion criteria, of which, 9 were retrospective and 1 prospective. A total of 6.214 women with JIA (with 6.811 pregnancies) and 18.659.513 healthy controls (with 21.339.194 pregnancies) were included in this review.Concerning maternal outcomes, delivery by caesarian section (CS) was more frequent among JIA women (in 4 out of 6 studies). Pre-eclampsia was referred in 3 out of 6 studies and a higher risk of vaginal bleeding and placenta previa in one additional study. No study found an increased risk for gestational diabetes or hypertension in pregnant women with JIA.Regarding fetal outcomes, 8 studies revealed significantly increased of pre-term birth (only in first births in one study) but one study didn’t show any increased risk. Two studies showed a higher risk of small gestational age (SGA) and in another 2, increased risk for low birth weight (LBW). No evidence of increased risk of major congenital malformations.Conclusion:This systematic review suggests an increased risk for pre-eclampsia, preterm birth, delivery by CS, SGA and LBW, among pregnant women with JIA. Conclusions should be carefully interpreted, giving the heterogeneity of studied populations regarding demography, disease type, disease activity, and prescribed medication.Disclosure of Interests:None declared

Background:The response to treatment in spondylarthropaties is heterogeneous, due to factors yet to be better described. For that reason, it is important to find tools that might help clinicians to decide what is the best available therapeutic option for each patient.Objectives:The goal of this study is to use comprehensive molecular profiling to characterize clinical response to therapy in a real-world setting. Specifically, to identify molecular biomarkers differentiating good responders and non-responders to TNF inhibitors (TNFi) treatment, using adalimumab, in radiographic axial spondyloarthritis | ankylosing spondylitis (r-axSpA|AS) patients context.Methods:Whole-blood mRNA and plasma proteins were measured in a cohort of biologic naïve r-axSpA|AS patients (n = 35) from the Bioefficacy study (Biomarkers identification of anti-TNF alpha agent efficacy in AS patients using RNA sequencing and mass spectrometry), pre and post (14 weeks) TNFi treatment using adalimumab. Response to treatment was categorized according to ASAS20. Results of differential expression analysis were used to identify the most enriched pathways and in predictive models to distinguish responses to TNFi.Results:A treatment-related signature, independent of the type of response, suggests a reduction in inflammatory disease activity. We found genes and proteins robustly differentially expressed between baseline and week 14 in responders, including the GWAS AS-associated genes TNFRSF1A, FCGR2A, TYK2, TBKBP1, IL1R1, IL6R, ICOSLG, IL7R, HHAT and LTBR. Moreover, CRP and HP proteins showed strong and early decrease in the plasma of AS patients, while a cluster of apolipoproteins (APO1, APO2, APO3) showed an increased expression at week 14. Good responders to TNFi treatment tend to have higher expression of innate immunity genes at baseline, and lower expression of markers associated with adaptive immunity, particularly B-cells. A logistic regression model incorporating ASDAS-CRP, gender and Gene x, the top differentially expressed gene at baseline between responders and non-responders, enabled an accurate prediction of response to adalimumab in our cohort (AUC=0.97).Conclusion:Differences in disease activity and/or innate/adaptive immune cell type composition at baseline may be a major contributor to response to adalimumab in r-axSpA|AS. Alternatively, a model including clinical and gene expression variables could be considered, particularly in patients with mild disease activity.Disclosure of Interests:None declared

Background:Early diagnosis of axial Spondyloarthritis (axSpA) represents a major clinical challenge nowadays. Increasing evidence has determined that early diagnosis, prompt treatment initiation and early achievement of remission are the best predictors of long-term clinical, functional and radiographic outcomes. New tools to support the diagnosis are needed.Objectives:This study aims to identify differentially expressed genes that may improve the current clinical diagnosis approach for early axSpA.Methods:A cross-sectional study was conducted on 50 participants, 25 patients with axSpA (according to ASAS criteria) and 25 Healthy Controls, matched by gender, age and levels of physical activity. Peripheral blood samples were collected and RNA-Seq technology was performed. Normalization of raw data, and identification of differentially expressed genes was obtained using edgeR and limma-voom R packages. Gene Set Enrichment Analysis (GSEA) and Functional Enrichment analysis using Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) annotations were also performed. A number of Differently Expressed Genes were highlighted.Results:311 genes were identified as being significantly differentially expressed between patients and controls. In details, 129 downregulated (7 genes have fold change more than 1) and 182 upregulated genes (3 genes have fold change more than 1) are highlighted. These genes are mostly involved in Myogenesis, Innate Immune Signalling and JAK/STAT pathways. Several genes with functions of skeletal muscle development and muscle contraction were identified.Conclusion:The evidence disclosed that regulation of muscle development and contraction may be also engaged in physiopathology mechanisms of axSpA. These new cues open new perspectives for diagnosis and therapeutic approaches in axSpA.Acknowledgments:To all patients and healthy people who participate in MyoSpA studyDisclosure of Interests:Atlas Mashayekhi Sardoo: None declared, Daniel Sobral: None declared, Lucia Domingues: None declared, Santiago Rodrigues-Manica Speakers bureau: Jansse, MSD, Novartis, Rita Pinheiro Torres: None declared, Agna Neto: None declared, Patricia Alves: None declared, Julia Costa: None declared, Ana Rita Grosso: None declared, Jaime Branco Speakers bureau: Vitoria, Fernando Pimentel dos Santos Speakers bureau: Novartis, Pfizer, Biogen, Vitoria