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Objective: Inflammatory hand arthritis (IHA) results in impaired function. Local gene therapy with ART-I02, a recombinant adeno-associated virus (AAV) serotype 5 vector expressing interferon (IFN)-beta, under the transcriptional control of nuclear factor kappa-B responsive promoter, was preclinically shown to have favorable effects. This study aimed to investigate the safety and tolerability of local gene therapy with ART-I02 in patients with IHA.Methods: In this first-in-human, dose-escalating, cohort study, 12 IHA patients were to receive a single intra-articular (IA) injection of ART-I02 ranging 0.3 x 10(12)-1.2 x 10(13) genome copies in an affected hand joint. Adverse events (AEs), routine safety laboratory and the clinical course of disease were periodically evaluated. Baseline- and follow-up contrast enhanced magnetic resonance images (MRIs), shedding of viral vectors in bodily fluids, and AAV5 and IFN-beta immune responses were evaluated. A data review committee provided safety recommendations.Results: Four patients were enrolled. Long-lasting local AEs were observed in 3 patients upon IA injection of ART-I02. The AEs were moderate in severity and could be treated conservative. Given the duration of the AEs and their possible or probable relation to ART-I02, no additional patients were enrolled. No systemic treatment emergent AEs were observed. The MRIs reflected the AEs by (peri)arthritis. No T-cell response against AAV5 or IFN-beta, nor IFN-beta antibodies could be detected. Neutralizing antibody titers against AAV5 raised post-dose.Conclusion: Single IA doses of 0.6 x 10(12) or 1.2 x 10(12) ART-I02 vector genomes were administered without systemic side effects or serious AEs. However, local tolerability was insufficient for continuation. (C) 2021 Published by Elsevier Ltd on behalf of Osteoarthritis Research Society International.

Background:Systemic Sclerosis (SSc) is a systemic autoimmune disease that carries the highest mortality burden among the rheumatic diseases. Disease risk and course are difficult to predict in individual patients, and anti-inflammatory and B-cell depleting therapies show varying results. >95% of SSc patients harbor autoantibodies. Among those, anti-topoisomerase antibodies (ATA) and anti-centromere antibodies (ACA) are most prevalent, mutually exclusive in individual patients and associate with distinct disease phenotypes. Despite these associations, the clinical value of both ATA and ACA for patient stratification within these phenotypes is limited. Here, we hypothesized that phenotypic and functional characteristics of the underlying autoreactive B cell responses could allow insights in differential ‘immunological disease activity’ in individual patients, thereby providing indications as to potential drivers of these responses as well as granularity as to which patients may benefit from targeted interventions.Objectives:To assess phenotypic and functional characteristics of anti-topoisomerase and anticentromere specific B cell responses in individual patients with SSc.Methods:Peripheral blood mononuclear cells (PBMC) from ATA- and ACA-positive SSc patients were cultured without stimulation or in the presence of CD40L-expressing fibroblasts, IL-21 and BAFF. Following culture, ATA- and ACA-IgG and -IgA were measured in culture supernatants by ELISA. In addition, PBMC were depleted of circulating plasmablasts by fluorescence activated cell sorting (FACS), and isolated plasmablasts were cultured separately. Furthermore, the presence of antigen-specific plasmablasts was confirmed by ELISPOT. Finally, the degree of spontaneous ATA secretion was correlated to the presence or absence of interstitial lung disease (ILD; based on high-resolution computed tomography). Healthy donors and patients with rheumatoid arthritis served as controls.Results:We observed that individual ATA- and ACA-positive SSc patients harbored circulating B cells that secrete either ATA-IgG or ACA-IgG upon stimulation, depending on their serotype. In addition, we noted spontaneous secretion of ATA-IgG and, more remarkably, extensive secretion of ATA-IgA in ATA-positive patients. This degree of spontaneous, antigen-specific IgA secretion was specific for the ATA response, while spontaneous ACA-IgA secretion was undetectable in patients harboring ACA. FACS experiments and ELISPOT showed that the spontaneous ATA-IgA and -IgG secretion was attributable to circulating plasmablasts. Of note, the degree of spontaneous ATA-IgG secretion was remarkably higher in patients with ILD than in those without.Conclusion:Our findings demonstrate that individual ATA-positive SSc patients harbor activated ATA-IgG and ATA-IgA B cell responses, as indicated by the spontaneous secretion of both ATA isotypes by circulating plasmablasts. Importantly, by taking the presence of plasmablasts as a proxy for recent B cell activation, our data suggest a link between the activity of the antigen-specific B cell response and the presence of ILD. In contrast, the ACA B cell response was far less active and lacked the active IgA component, which suggests a difference in the triggers driving these autoreactive B cell responses in patients. In fact, the remarkable ATA-IgA secretion points towards a potential mucosal trigger of the ATA response, which may be continuously active in individual patients.Disclosure of Interests:None declared.

Background:Cognitive impairment is common in patients with systemic lupus erythematosus (SLE) and neuropsychiatric (NP) symptoms, but the exact underlying structural brain correlates are unknown.Objectives:We aimed to compare cognitive function between groups of patients with different phenotypes of (NP)SLE and assessed the association between brain volumes, white matter hyperintensity (WMH) volume and cognitive function.Methods:Patients who visited the NPSLE clinic of the Leiden University Medical Center between 2007-2015 were included in this study (n=151; 42 ± 13 years, 91% female). In a multidisciplinary consensus meeting, phenotypes were established and neuropsychiatric symptoms were attributed to SLE (NPSLE, inflammatory (n=24) or ischemic (n=12)) or to minor involvement of SLE or other causes (minor/non-NPSLE (n=115)). All patients underwent standardized cognitive assessment of the four cognitive domains: global cognitive functioning (GCF), learning and memory (LM), executive functioning and complex attention (EFCA) and psychomotor speed (PS)). Cognitive dysfunction was defined as a T-score 1.5 cm were excluded. Cognitive function (Z-score) was compared between different NPSLE phenotypes using multiple regression analyses corrected for age, sex and education. Associations between brain volumes, WMH and cognitive function were assessed per phenotype using multiple regression analyses corrected for age, sex and intracranial volume.Results:Global cognitive functioning was impaired in 5%, learning & memory in 46%, and executive functioning & complex attention in 39% and psychomotor speed in 46% of all patients. Patients with inflammatory NPSLE showed the most cognitive impairment and reduced cognitive function compared to ischemic NPSLE (all domains) and minor/non-NPSLE (EFCA) (p Lower total brain volume and grey matter volume were associated with lower cognitive functioning in all domains (β: 0.00/0.01 (0.00; 0.01)) and lower white matter volume associated with lower LM, EFCA and PS (β: 0.00/0.01 (0.00; 0.01)) in all patients. Higher WMH volume associated with lower psychomotor speed (β: -0.14 (-0.32; -0.02)), especially in patients with inflammatory NPSLE (β: -0.36 (-0.60; -0.12).Conclusion:Reduced brain volume leads to reduced cognitive function in multiple cognitive domains in all patients with SLE and neuropsychiatric symptoms. Increased WMH volume leads to reduced psychomotor speed, especially in patients with inflammatory NPSLE.Table 1.Prevalence of cognitive impairment in patients with minor/non-NPSLE, inflammatory NPSLE and ischemic NPSLEGlobal cognitive functioningLearning &memoryExecutive functioning & complex attentionPsychomotor speedAll patients(n = 151)8 (5)70 (46)57 (39)69 (46)Inflammatory NPSLE(n = 24) 3 (13) 14 (58) 12 (50) 12 (50)Ischemic NPSLE(n = 12) 0 (0) 6 (50) 2 (17) 2 (17)Minor/non-NPSLE(n = 115) 5 (4) 50 (44) 43 (38) 55 (49)NPSLE = neuropsychiatric systemic lupus erythematosus.Data represent n (%) of patients with cognitive impairment in the mentioned cognitive domain. Cognitive impairment was defined as cognitive function at least 1SD lower than the mean of an age, sex and education matched general Dutch population. The percentages were calculated from total number of patients with available scores: Global functioning: 23/24 inflammatory NPSLE and 113/115 minor/non-NPSLE; psychomotor speed 113/115 minor/non-NPSLE, executive function & complex attention: also 113/115. All tests were available for ischemic NPSLE.Disclosure of Interests:None declared

Background:Patients who achieve remission promptly could have a specific genetic risk profile that supports regaining immune tolerance. The identification of these genes could provide novel drug targets.Objectives:To test the association between RA genetic risk variants with achieving remission at 6 months.Methods:We computed genetic risk scores (GRS) comprising of the RA susceptibility variants1 and HLA-SE status separately in 4425 patients across eight datasets from inception cohorts. Remission was defined as DAS28CRPResults:Evaluation of the complete dataset, baseline clinical variables did not differ between patients achieving remission and those who did not (Table 1). Distribution of GRS was consistent between datasets. Neither GRS nor HLA-SE was associated with baseline DAS2DAS (OR1.01; 95% CI 0.99-1.04). A fixed effect meta-analysis (Figure 1.) showed no significant effect of the GRS (OR 0.99; 95% CI 0.94-1.03) or HLA-SE (OR 0.8CRP87; 95% CI 0.75-1.01) on remission at 6 months.Table 1.Summary of the data separated by disease activity after 6 months.allRemission at 6 monthsNo remission at 6 monthsN4425*15582430Age, mean (sd)55.38 (13.87)5517 (14.09)55.62 (13.59)Female %68.98%65.43%70.73%ACPA+ %61.94%63.53%61.67%Baseline DAS28, mean (sd)4.76 (1.22)4.47 (1.23)5.1 (1.15)*not all patients had 6 months dataConclusion:In these combined cohorts, RA genetics risk variants are not associated with early disease remission. At baseline there was no difference in genetic risk between patients achieving remission or not. Studies encompassing other genetic variants are needed to elucidate the genetics of RA remission.References:[1]Knevel R et al. Sci Transl Med. 2020;12(545):eaay1548.Acknowledgements:This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 777357, RTCure.This project has received funding from Pfizer Inc.Disclosure of Interests:Samantha Jurado Zapata: None declared, Marc Maurits: None declared, Yann Abraham Employee of: Pfizer, Erik van den Akker: None declared, Anne Barton: None declared, Philip Brown: None declared, Andrew Cope: None declared, Isidoro González-Álvaro: None declared, Carl Goodyear: None declared, Annette van der Helm - van Mil: None declared, Xinli Hu Employee of: Pfizer, Thomas Huizinga: None declared, Martina Johannesson: None declared, Lars Klareskog: None declared, Dennis Lendrem: None declared, Iain McInnes: None declared, Fraser Morton: None declared, Caron Paterson: None declared, Duncan Porter: None declared, Arthur Pratt: None declared, Luis Rodriguez Rodriguez: None declared, Daniela Sieghart: None declared, Paul Studenic: None declared, Suzanne Verstappen: None declared, Leonid Padyukov: None declared, Aaron Winkler Employee of: Pfizer, John D Isaacs: None declared, Rachel Knevel Grant/research support from: Pfizer

Background:Besides anti-citrullinated protein antibodies (ACPA), rheumatoid arthritis patients (RA) often display autoantibody reactivities against other post-translationally modified (PTM) proteins, more specifically carbamylated and acetylated proteins. Immunizing mice with one PTM results in an anti-modified protein antibody (AMPA) response recognizing multiple PTMs. Furthermore, human AMPA, isolated based on their reactivity to one PTM, cross-react with other PTMs at the monoclonal and polyclonal level. However, it is unclear whether the AMPA reactivity profile is “fixed” in time, or whether consecutive exposure to different PTMs can shape the evolving AMPA-response.Objectives:To investigate the evolution of the AMPA response in mice with controlled exposure to PTMs as well as in AMPA-positive humans.Methods:Mice were immunized with acetylated (or carbamylated) protein (ovalbumin) twice or cross-immunized with an acetylated and then a carbamylated protein (or vice versa) and their serum was analyzed for AMPA responses with ELISA using a different backbone protein (fibrinogen) bearing the same modifications. Longitudinally collected serum samples of human individuals at risk of RA and with early RA were tested to investigate the evolution of the AMPA responses in humans.Results:Mice immunized twice with either solely acetylated or solely carbamylated ovalbumin (AcOVA or CaOVA) developed reactivity against both acetylated and carbamylated antigens. Irrespective of the PTM used for the first immunization, a booster immunization with the other PTM resulted in increased titers to the second/booster PTM (Figure 1A), suggesting that immunization with a defined PTM-antigen leads to the generation of anti-PTM memory B cells able to cross-recognize other PTMs. Furthermore, immunizing with CaOVA and boosting with AcOVA (or vice versa) skewed the overall AMPA-response profile towards a relatively higher reactivity against the “booster” PTM (Figure 1B). Human data also illustrated dynamic changes in AMPA reactivity profiles in both individuals at risk of RA and in early RA patients (not shown).Conclusion:The relationship between different reactivities within the AMPA response is dynamic. The initial exposure to a PTM antigen induces cross-reactive response that can be boosted by the same or other PTMs. The overall reactivity pattern can be skewed by subsequent exposure to other PTMs. These data might explain temporal changes in the reactivity profile of the AMPA response and point to the possibility that the PTM responsible for the initiation of the AMPA response may differ from the PTM predominantly recognized later in time.Disclosure of Interests:None declared

Background:Disease course in Systemic Sclerosis (SSc) ranges from mild, to severe with progressive organ involvement within months. Guidelines for follow-up are mainly based on expert consensus, and advocate annual assessment. So far, no data driven guidelines exist that describe tailormade systematic assessments for individual patients in line with individual disease course.Objectives:To develop a prediction model to guide annual assessment of SSc patients tailored in accordance to disease activity.Methods:A machine learning approach was used to develop a model that can identify patients without disease progression. SSc patients included in the prospective Leiden SSc cohort and fulfilling the ACR/EULAR 2013 criteria were included. The primary endpoint in the prediction model was disease progression which was defined as progression in ≥1 organ system, and/or start of immunosuppression or death between the two most recent visits. Using elastic-net-regularization, and including 90 independent clinical variables (100% complete), we trained the model on 75% and validated it on 25% of the patients in order to perform internal validation of the final model. We optimized the model on negative predictive value (NPV) to minimize the likelihood of missing progression. By expert assessment of the test characteristics, including swarm plots of the probability scores, cut-offs were identified for low, intermediate and high risk for disease progression.Results:Of the 492 SSc patients (range of follow-up: 2-10yrs), disease progression during follow-up was observed in 52% (median time 4.9yrs), including myocardial progression in 29%, lung progression in 23%, skin progression in 16%, and death in 12%. Performance of the model in the test set showed an AUC-ROC of 0.66. Probability score cutoffs were defined: low risk for disease progression (0.223, NPV:0.78; 44%). The predictive variables included in the model were: previous use of cyclophosphamide or corticosteroids, start with immunosuppressive drugs, previous gastrointestinal progression, previous cardiovascular event, pulmonary arterial hypertension, modified Rodnan Skin Score, creatinine kinase, and diffusing capacity for carbon monoxide.Conclusion:Our machine-learning-assisted model for disease progression enabled us to classify 29% of SSc patients as ‘low risk’. In this group annual assessment programs could be less extensive than indicated by international guidelines.Baseline characteristicsTotaln=492Non-ProgressorsN=235ProgressorsN=257DemographicsFemale, n (%)389 (79)193 (82)196 (76)Age, mean (SD)55 (14)55 (15)55 (13)Disease duration nonRP, median (IQR)3.2 (0.9-10.3)3.5 (0.8-10.5)3.6 (1.1-9.3)Organ involvementDcSSc, n (%)118 (24)34 (15)84 (33)DLCO% of pred, mean (SD)66 (18)69 (18)64 (17)FVC% of pred, mean (SD)98 (23)96 (24)97 (21)ILD on HRCT, n (%)183 (37)66 (28)117 (46)PAH, n (%)26 (5)10 (4)16 (6)GAVE, n (%)9 (2)4 (2)5 (2)Cardiac involvement, n (%)28 (6)14 (6)14 (5)Myositis, n (%)8 (2)6 (3)2 (1)Renal crisis, n (%)14 (3)6 (3)8 (3)AutoantibodiesAnti-centromere, n (%)194 (39)118 (50)76 (30)Anti-topoisomerase, n (%)116 (24)42 (18)74 (29)RP=raynaud phenomenon, dcSSc= diffuse cutaneous systemic sclerosis, mRSS=modified rodnan skin score, DU=digital ulcera, DLCO= single-breath diffusing capacity for carbon monoxide, FVC= forced vital capacity, ILD=interstitial lung disease, HRCT= high resolution computed tomography, PAH= pulmonary arterial hypertension, GAVE= gastric antral vascular extasia.Disclosure of Interests:None declared

Background:Discontinuation of glucocorticoids (GC) as bridging therapy in rheumatoid arthritis (RA) treatment is recommended as rapidly as clinically feasible. Little is known about the rate of, and possible characteristics associated with successful GC discontinuation.Objectives:To evaluate the success rate of GC discontinuation, and to study which factors are associated with successful GC discontinuation.Methods:Data from two treat-to-target studies; BeSt (target DAS ≤2.4, LDA), and IMPROVED (target DAS Results:From the 131 patients initiating combination therapy with prednisone in the BeSt study, 93 attempted discontinuation. Primary discontinuation was successful in 60% (56/93) and secondary discontinuation in 54% (19/35). A lower DAS at the visit prior to GC discontinuation and ACPA negativity were associated with successful discontinuation (table 1). Of the 610 patients in the IMPROVED, 400 attempted discontinuation. Primary discontinuation was successful in 61% (242/400), and secondary in 51% (71/139). A lower DAS both at baseline and at the visit prior to GC discontinuation were associated with successful discontinuation (table 1).Conclusion:Primary GCs discontinuation was successful in approximately 60% and secondary in 50% of patients, independent of the treatment target and associated threshold for GC discontinuation. Most baseline characteristics were not predictive of successful GC discontinuation, but ACPA negativity (only in BeSt), baseline DAS (only in IMPROVED) and in both studies DAS prior to GC discontinuation were predictive for successful discontinuation. Based on this data it seems that ‘standard’ baseline characteristics are insufficient to ‘personalize’ the duration of temporary GC bridging but the DAS at the moment of GC discontinuation might give guidance.Table 1.Results logistic regression analysesUnivariableMultivariableaR2= 0.173BeStOR (95% CI)p-valueOR (95% CI)p-valueAge, year1.00 (0.98; 1.03)0.98Gender, female0.51 (0.24; 1.09)0.08Symptom duration BL, weeks1.00 (0.99; 1.01)0.61DAS at BL0.92 (0.61; 1.40)0.70DAS prior to discontinuation0.13 (0.05; 0.33)0.11 (0.04; 0.30)RF, positive1.28 (0.62; 2.69)0.502.24 (0.81; 6,17)0.12ACPA, positive0.70 (0.34; 1.43)0.320.32 (0.12; 0.86)0.02Erosions, present at BL0.65 (0.28; 1.49)0.31UnivariableMultivariableaR2= 0.065IMPROVEDOR (95% CI)p-valueOR (95% CI)p-valueAge, year1.00 (0.99; 1.02)0.64Gender, female0.62 (0.43; 0.89)0.010.75 (0.51; 1.11)0.15Symptom duration BL, weeks1.00 (0.99; 1.00)0.430.99 (0.99; 1.00)0.08DAS at BL0.80 (0.65; 0.98)0.030.78 (0.62; 0.98)0.03DAS prior to discontinuation0.24 (0.15; 0.38)0.24 (0.14; 0.40)RF, positive0.82 (0.57; 1.17)0.27ACPA, positive0.95 (0.66; 1.35)0.76Erosions, present at BL0.80 (0.49; 1.29)0.35ACPA: anti-citrullinated protein antibodies; BL: baseline; DAS: disease activity score; RF: rheumatoid factor. α The final multivariable logistic regression model was based on stepwise forward and backward selection of predictors, both resulting in the same final model.Acknowledgements:We would like to thank all patients for their contribution as well as the rheumatologists who participated in the BeSt study group and in the IMPROVED-study group. We would also like to thank all other rheumatologists and trainee rheumatologists who enrolled patients in these studies, and all research nurses for their contributions.Disclosure of Interests:Johanna M. Maassen: None declared, Raquel Dos-Santos: None declared, Sytske Anne Bergstra: None declared, Robbert Goekoop: None declared, Thomas Huizinga: None declared, Cornelia Allaart Grant/research support from: The original BeSt study was realized with a government grant from the Dutch College of Health Insurance Companies, with additional funding from Schering-Plough and Janssen. the IMPROVED study was financially supported by AbbVie in the first year.

Background:The presence of a ‘fog’ is frequently reported by patients with systemic lupus erythematosus (SLE). However, little is known about this lupus fog: it is thought to be a result of cognitive dysfunction, but fogs can also be the result of dissociation. The Dissociative Experience Scale-II (DES) is a standardized tool to study dissociation. In the general adult population, scores range from 4.4-14.1-3Objectives:We aimed to study the prevalence of dissociative symptoms including dissociative fog in patients with SLE and neuropsychiatric symptoms.Methods:Patients visiting the tertiary referral center for neuropsychiatric systemic lupus erythematosus (NPSLE) of the LUMC between 2007-2019 were included. All patients underwent a standardized multidisciplinary assessment. Patients were classified as NPSLE if neuropsychiatric symptoms were attributed to SLE and immunosuppressive or anticoagulant therapy was initiated, otherwise patients were classified as minor/non-NPSLE. Dissociation was studied using the DES. The DES separates different types of dissociative symptoms: amnesia, absorption/imagination and derealization/depersonalization. It also contains one question regarding evaluating the presence of a dissociative fog: “Some people sometimes feel as if they are looking at the world through a fog, so that people and objects appear far away or unclear”. All statements (n = 28) regarding dissociative symptoms are rated from ‘none of the time’ to ‘all of the time’ (0-100%); scores >25 are considered abnormal. A multiple regression analysis (MRA) were performed to compare dissociation in patients with and without NPSLE. DES results are presented as median (range) and MRA as odds ratio (OR) and 95% confidence interval (CI).Results:DES questionnaires were available for 337 patients, of which 97 had the diagnosis NPSLE (29%). Mean age in patients with NPSLE was 41 ± 13 years and 84% was female. In minor/non-NPSLE, median age was 44 ± 14 years and 87% was female.Median dissociation was 7 (0-75) and did not differ between patients with minor/non-NPSLE and NPSLE (OR: 1.0 (95% CI: -0.9; 1.1)). The most common type of dissociation was absorption/imagination (median: 12, range 0-75) and depersonalization/derealization was infrequent (median: 1, range 0-84). 43 patients (13%) had an abnormal score (>25) on the dissociative fog question.Conclusion:Dissociative symptoms are within normal range in patients with SLE and neuropsychiatric symptoms, regardless of underlying etiology. Dissociative fog seems uncommon and therefore lupus fog is most likely not the result of dissociation.References:[1]Bernstein EM and Putnam FW. Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 1986; 174: 727-735. 1986/12/01. DOI: 10.1097/00005053-198612000-00004.[2]Maaranen P, Tanskanen A, Honkalampi K, et al. Factors associated with pathological dissociation in the general population. Aust N Z J Psychiatry 2005; 39: 387-394. 2005/04/30. DOI: 10.1080/j.1440-1614.2005.01586.x.[3]van IJzendoorn MH and Schuengel C. The measurement of dissociation in normal and clinical populations: Meta-analytic validation of the Dissociative Experiences Scale (DES). Clinical Psychology Review 1996; 16: 365-382. DOI: 10.1016/0272-7358(96)00006-2.Table 1.Presence of dissociation in patients with SLE and neuropsychiatric symptomsTotal cohort(n = 337)Minor/non-NPSLE(n = 240)NPSLE(n = 97)DES (median, range)Total questionnaire7 (0 - 75)8 (0 - 66)6 (0 – 75)Amnesia5 (0 - 76)5 (0 - 68)4 (0 - 76)Absorption/imagination12 (0 – 75)13 (0 – 75)10 (0 – 73)Depersonalization/derealization1 (0 – 84)1 (0 – 73)1 (0 – 84)Dissociative fog* 0 (0-100)0 (0-100)0 (0-100)DES = Dissociative Experience Scale NPSLE = neuropsychiatric systemic lupus erythematosus.*Dissociative fog is question 28 of the DES-IIDisclosure of Interests:None declared

Career situation of first and presenting author Student for a master or a PhD. Introduction Systemic Sclerosis (SSc) is a rare, heterogeneous autoimmune disease characterized by microvascular damage, organ fibrosis and immune dysfunction. Autoantibodies are detected in >95% of patients, the most prevalent being anti-centromere (ACA) and anti-topoisomerase (ATA) antibodies. Although used for diagnosis, little is known about the underlying auto-reactive B cell responses. In particular, the ACA B cell response has been poorly studied. Objectives Characterization of the ACA B cell response in SSc patients. Methods ACA IgG, IgA and IgM levels were measured in serum samples of 167 ACA IgG+ SSc patients. Patients were divided in a SSc (fulfilling ACR 2013 criteria, n=132) and a very early SSc group (fulfilling VEDOSS criteria, n=35). Additionally, PBMCs from ACA IgG+ SSc patients (and ATA IgG+ SSc and healthy donors (HD) as control) were cultured either in the presence of CD40L expressing fibroblasts, IL-21 and BAFF or without stimulation. Levels of ACA IgG, IgA and IgM (and total Ig) were measured after one week of culture using ELISA. Results ACA IgG+ SSc patients displayed a broad isotype usage with 75% being ACA IgA+ and 68% being ACA IgM+ in serum. Patients within the SSc group showed higher ACA IgG levels and a higher percentage of ACA IgM positivity compared to the very early SSC group. ACA IgG, IgA and IgM could be measured in ACA SSc PBMC culture medium following stimulation, but not in ATA SSc and HD, indicating the presence of circulating ACA B cells of all three isotypes. In cultures that yielded sufficient Ig production, ACA IgG was detectable in 7/9 ACA SSc patients, ACA IgA in 3/7 and ACA IgM in 2/7. Furthermore, ACA IgG production was also detected in the absence of stimulation in 5/9 patients, suggesting the presence of ACA-producing plasmablasts in the circulation. No spontaneous production of anti-Tetanus Toxoid antibodies, a control recall response, was observed. Conclusions ACA+ SSc patients display a broad range of isotype usage in their ACA response, reflected both by ACA serum levels and presence of ACA IgG-, IgA- and ACA IgM-producing B cells in the peripheral blood. Additionally, ACA IgG production by unstimulated PBMCs points towards continuous differentiation of memory cells into antibody secreting cells. These data, together with differential isotype profiles between very early SSc and SSc patients, provide insight into the ACA B cell response and its potential involvement in disease-relevant pathogenetic processes. Disclosure of Interest None declared.

Background:BMI appears to be associated with treatment response on TNFi(nhibitors) in rheumatoid arthritis (RA), but large heterogeneity between studies exists. More extreme BMI categories are rarely studied and it is unclear if differences exist between various TNFi.1Table 1Characteristics of RA patientsFemale, n (%)935 (79.8)Age, years*51.0 ±13.7Current smokers, n (%)256 (23.2)RF Positivity, n (%)404 (55.6)Anti-CCP Positivity, n (%)430 (58.2)X-ray Erosion, n (%)317 (61.9)ESR, mm/h*31.2±21.9CRP, mg/L*17.2±3.9DAS 28-CRP*3.8±1.6VAS global*46.6±28.6HAQ*0.9±0.7First TNFi Etanercept, n (%)525 (38.7) Adalimumab, n (%)379 (27.9) Infliximab, n (%)118 (8.7) Certolizumab, n (%)188 (13.8) Golimumab, n (%)147 (10.9)* mean ±S.DRF, Rheumatoid factor; Anti-CCP, Anti- cyclic citrullinated peptid; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; DAS28–CRP, Disease Activity Score using 28 joints–CRP; VAS, Visual analog scale; HAQ, Health Assessment QuestionnaireObjectives:To study whether there is an association between BMI category and drug survival in RA patients starting treatment with various TNFi in a real life longitudinal international registry.Methods:Data from 5230 RA patients starting a TNFi were included from the METEOR registry. Timing of follow-up visits was daily practice based. Follow-up was censored at 5000 days (±13.5 years). Patients were divided into 6 BMI categories (WHO definition): underweight BMI 40. Missing data were imputed using chained equations. The association between BMI category and time on treatment was investigated using Kaplan-Meier (KM) curves and Cox regression analyses, for time on first TNFi and for the first prescribed course of adalimumab (ADA), etanercept (ETA) and infliximab (IFX) separately. All analyses were adjusted for the potential confounders age, gender, smoking, baseline DAS28, concomitant glucocorticoid use and country. Potential effect modification by reported pain was tested by adding an interaction term between BMI category and baseline pain category (VAS pain 0-25, 25-50, 50-75 and 75-100).Results:Most patients had a normal weight (46%) or pre-obesity (32%). 4% of patients were underweight, 10% had obesity class I, 3% obesity class II and 1% obesity class III. N=2936 patients ever started ETA, n=2069 ADA, n=1390 IFX, n=263 certolizumab and n=84 golimumab. The KM curve in fig 1A shows TNFi survival in patient starting their first TNFi per BMI category. Patients with normal weight and pre-obesity had longest drug survival and patients with obesity class II and especially patients with obesity class III had shortest drug survival. The adjusted Cox regression support these findings, with statistically significantly shorter drug survival for patients with obesity class III [HR (95% CI) 1.67 (1.29; 2.18)] and class II [1.28 (1.06; 1.54)], but also for underweight patients [1.3 (1.07; 1.58)], compared to normal weight patients. KM curves for individual TNFi showed shorter drug survival on ADA for patients with obesity class II and III (fig 1B), on ETA for patients with obesity, especially in class III (fig 1C) and on IFX, for patients with obesity class II and III and underweight patients (fig 1D). After adjustment in Cox regression, statistical significant BMI-drug survival associations remained for patients with pre-obesity starting ADA [HR (95% CI) 0.86 (0.75; 0.99)], for patients starting ETA with obesity class II [HR (95% CI) 1.27 (0.98; 1.65) or class III [1.79 (1.25; 2.55)] and for patients on IFX who were underweight [HR (95% CI) 1.82 (1.20; 2.76)] or in obesity class II [1.49 (0.98; 2.26)]. No effect modification was found for reported pain.Conclusion:Both underweight (as identified in IFX treated patients) and overweight patients (in ADA, ETA and IFX treated patients) discontinued a first TNFi treatment earlier than normal weight patients. Reported pain was not the main determinant. It remains uncertain what determines TNFi survival in individual patients.References:[1] Singh, et al.PloS One2018; 13:e0195123Disclosure of Interests:Sytske Anne Bergstra: None declared, David Vega-Morales: None declared, Elizabeth Murphy: None declared, Marieke de Buck: None declared, Karen Solomon-Escoto: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Cornelia Allaart: None declared

Background In patients with synovitis, the question is ‘Which disease does this patient have?’ However, traditional tests often only inform us about disease presence yes/no and disease discriminating symptoms often take a while to arise. Time independent information, such as genetics, might accelerate the diagnostic process. As increasing number of patients have genotyping data available in medical records prior to their visit, the question emerges: can genetic data facilitate disease differentiation in early disease? Objectives Proof of principle study to test the differentiating ability of genetic profiles in patients with synovitis. Methods We studied the most common rheumatologic diseases: rheumatoid and psoriatic arthritis, SLE, spondyloarthropathy and Gout. The population level disease probability for each disease comprised a sex adjusted disease prevalence and a weighted genetic risk score comprised of risk SNPs’ odds ratio from literature. Within case genetic probabilities (GProb) were obtained through normalisation of the population risk assuring a patient’s total disease probability of 1. So, each patient got a probability for each disease. GProb was developed in a simulated dataset and tested in Validation dataset of 1,211 rheumatology cases identified with ICD codes from 62,512 patients Replication dataset of 248 rheumatology cases identified by chart–review from 15,047 patients Clinical setting of prospective selected patients that presented with synovitis at the rheumatology outpatient clinic (n=242). Here, GProb was calculated for the five diseases plus the category ‘Other’. Having multiple GProbs for each patient, we tested whether the GProbs referring to the patient’s real disease were higher than those that referred to the other phenotypes. We used multinomial logistic regression with the six diseases as the dependent variables to test the additive value of GProb on top of clinical information. Results There was a strong significant correlation between GProb and the disease status (r=0.27 P We observed a higher correlation with disease status in the more precisely identified cases (r=0.49 P Also in a prospective setting, the GProb performed well (P The clinical information alone explained 41% of the variance in the final diagnosis. Adding GProb significantly improved the predictive value (expl. variance increased to 51% p=0.0008). Sensitivity analysis showed that the results were not driven by one disease. The graph depicts the mean GProb (with range) of each quintile of GProbs on the x-axis and the corresponding proportion of those GProbs that matched with the patient’s real disease on the y-axis. The graph demonstrates that the genetic probability of the disease highly resembles the real disease risk. In case of a perfect test performance, the dots would lie exactly on the diagonal (dashed) line. Conclusions This study developed methodology for disease-discriminating tests. In patients with synovitis, genetic data can facilitate decision making in early disease by ruling out and pointing towards the most likely phenotype. Seeing the increasing importance of an early diagnosis in patients with synovitis, genetics can be considered as part of a patient’s medical history. Additional prospective studies will further need to validate this proof of principle study. Disclosure of Interest None declared

Background Systemic sclerosis (SSc) is a disease with considerable physical and psychosocial impact. Previous studies among partners of patients with other chronic diseases, such as Parkinson’s and stroke, showed that 6%–25% of caregivers experience high levels of stress related to caregiving. To our knowledge, the burden experienced by caregivers of patients with SSc has not been determined so far. Objectives To evaluate perceived strain, quality of life and health care needs among SSc caregivers. Methods During a patient information meeting, companions of SSc patients were invited to complete 3 questionnaires: 1. The Caregiver Strain Index questionnaire (CSI), in which a score ≥7 indicates high care burden, 2. Short Form-36 (SF-36): a measure of self-reported Quality of Life (QoL) and 3. a self-designed questionnaire on the needs and preferences for caregiving support. Caregivers with and without high care burden were compared regarding their general characteristics and Qol. Results Thirty-six SSc caregiver filled out questionnaires (n=31 completed the CSI questionnaire). Respondents were mostly men (64%), on average 62 years old (SD 14), 35% (n=11) had a paid job, and 50% (n=18) suffered from chronic disease. The majority was in a spousal relationship (75%) with the SSc patient and 56% of patients had been diagnosed with SSc more than 5 years ago. Nineteen percent of patients (n=7) needed daily personal caregiving and 25% (n=9) was transport-dependent. Median CSI was 2 (range 0 to 5), and 6/31 (19%) perceived high care burden(CSI ≥7). Caregivers with high care burden were significantly more often involved in daily personal caregiving of the patients (3/6 vs. 2/25). Although not statistically significant, all caregivers perceiving a high burden were spouses, while the remaining caregivers had varying relationships with SSc patients. SF-36 summary scale scores were similar in both groups (table 1). Regarding needs and preferences of caregivers, 15% (n=5) reported a need for additional individual information, and 21% (n=7) a need for contact with fellow caregivers of patients, preferably during information meetings. 1 Fisher’s exact 2 Mann-Withney U *n=35, **n=31, ***n=28, ****n=19 Conclusions Within a small group of SSc caregivers, 19% experienced high care burden. In particular caregivers involved in personal caregiving seem to be at risk for increased strain related to caregiving. The results of the current study can direct clinical practice aiming at support of the caregivers. Disclosure of Interest None declared

Background Synovial fluid (SF) is commonly used for diagnostic and research purposes since it is easily obtained and is thought to represent the local inflammatory environment. Common practice to obtain insight in the disease pathogenesis of arthritic diseases is the characterisation and quantification of synovial fluid cells and the measurement of inflammatory mediators. SF has a complex composition, containing hyaluronic acid which makes the fluid viscous and non-homogeneous, hampering subsequent analyses. Hyaluronic acid can be broken down by the addition of hyaluronidase, however, this is not commonly used in arthritic research. Objectives To determine the effect of hyaluronidase treatment on quantification and identification of SF cells and soluble mediators. Methods SF was obtained from twelve arthritis patients after knee aspirations as part of standard clinical care. Nine patients were diagnosed with rheumatoid arthritis, two with osteoarthritis and one with juvenile idiopathic arthritis. For cell analysis, synovial fluid was first centrifuged and the pellet was separated from the fluid. The fluid was subsequently treated with hyaluronidase and centrifuged again to isolate remaining cells. Cell numbers and phenotype were determined using flow cytometry. For soluble mediator measurements, 6–10 aliquots were taken and treated as represented in figure 1 resulting in set 1 and set 2. Set 1 contains replicates taken form SF before hyaluronidase treatment while set 2 mimics replicates which are taken after hyaluronidase treatment. Interleukin (IL)−8 was measured by ELISA and a total of seven fatty acid and oxidised fatty acid levels were determined using LC-MS/MS in all aliquots. Results Between 0.8%–70% of immune cells (median 5%) are lost when the SF is not treated with hyaluronidase. This percentage is higher for T and B cells: 7%–85% (median 22%) and 7%–88% (median 23%), respectively. To assess the variation between the soluble mediator concentrations in set 1 and set 2, the coefficients of variation (CV) of the replicate measurements were compared. Aliquots in set 2 showed a lower CV for the oxidised lipids 17-HDHA, leukotriene B 4 and prostaglandin E 2 for all patients tested. For IL-8, the oxidised lipid 15-HETE, and fatty acids arachidonic acid (AA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), it did not matter whether the aliquots were taken before or after hyaluronidase treatment. While in general the average levels of the soluble mediators tested were comparable between set 1 and set 2, we did observe large differences in IL-8 and AA levels in two independent patients. Conclusions Up to 70% of the synovial fluid cells are missed in analysis when the SF is not treated with hyaluronidase before cell isolation, leading to erroneous conclusion especially when investigating rare cells populations like antigen specific B or T cells, when searching for novel cell populations, or when correlations are made between clinical parameters and cell numbers. In addition, some cytokine as well as lipid levels determined in SF without hyaluronidase treatment might not accurately reflect their actual concentrations in SF. Disclosure of Interest None declared

Background Disease-modifying anti-rheumatic drug (DMARD)-free remission is an achievable outcome in rheumatoid arthritis (RA). The influence of treatment strategy on the ability to achieve and sustain this outcome is unclear. Therefore, we compared the prevalence and sustenance of DMARD-free remission in RA-patients treated in a trial with intensive DAS-steered care aimed at DMARD-free remission versus RA-patients treated to target in routine care. Methods 279 consecutive RA-patients (2010-criteria), diagnosed in the Leiden University Medical Centre between March 2007-September 2010, were studied. Of these, 155 participated in a DAS Results Patients receiving intensive treatment were more often ACPA-positive (59% vs 40%). DMARD-free remission was achieved by 35% of patients receiving intensive treatment and by 29% of patients receiving routine care (HR 1.2, 95% CI: 0.8 to 1.8). Within the ACPA-positive and ACPA-negative strata patient characteristics were similar, except for a younger age in patients receiving intensive treatment. Within ACPA-positive patients, DMARD-free remission was achieved more often in the intensive treatment group than in the routine care group (25% vs 6%, HR 4.9, 95%: CI: 1.4 to 17, corrected for age). In ACPA-negative patients no differences were observed (49% vs 44%, HR 1.1, 95% CI: 0.6 to 1.8, corrected for age). A late flare occurred in 20% of patients receiving intensive treatment and in 8% of patients receiving routine care (HR 2.3, 95% CI: 0.6 to 8.3). After excluding late flares from the remission group, the prevalence of DMARD-free sustained remission was not different for both treatment strategies in the total group (28% vs 27%, HR 1.0, 95% CI: 0.6 to 1.5). Also in the ACPA-positive group no significant effect remained (17% vs 6%, HR 3.1, 95% CI: 0.9 to 11, corrected for age). Conclusions An intensive treatment strategy was not associated with a higher prevalence of DMARD-free sustained remission compared to up-to-date routine treatment. Within ACPA-positive RA, intensive treatment resulted in more remission but also in more late flares. Together these data do not provide evidence to prioritise the studied intensive treatment strategy above current routine care. Disclosure of Interest None declared

Background Anti-citrullinated protein antibodies (ACPA) are one of the most important serological markers for rheumatoid arthritis (RA) and have been suggested to play a pathophysiologic role by directly binding to osteoclasts. However, the effect of ACPA on systemic bone mineral density (BMD) and in particular their effect on changes in BMD over time is currently unknown. Objectives The aim of this study was to determine whether ACPA associate with changes in BMD over time in patients with RA. Methods Yearly dual X-ray absorptiometry (DXA) scores were performed during 5 years of follow-up in 412 patients with recent-onset RA participating in the IMPROVED study1, a clinical trial in which patients were treated according to a remission- (disease activity score Results ACPA-positive patients had a significantly lower lumbar spine (p=0.04) and hip (p=0.01) Z-score at baseline. There was no difference in prevalence of osteoporosis/osteopenia at baseline between ACPA-positive and ACPA-negative patients (OR (95% CI) 1.02 (0.55 to 1.19)). We hypothesised that ACPA-positive patients would have more BMD loss over time compared to ACPA-negative patients. However, ACPA-positivity did not associate with a stronger decline in Z-score over time at lumbar (p=0.43) or femoral sites (p=0.67). Additionally, no effect of ACPA-positivity was found on the development of osteoporosis/osteopenia over time (p=0.23). Conclusions ACPA-positive patients have a significantly lower baseline BMD compared to ACPA-negative patients. Surprisingly, ACPA do not associate with a decrease in BMD over time in patients who were treated according to a tight control strategy. These results indicate that ACPA alone do not contribute to bone loss after disease onset in the absence of inflammation/disease activity. Reference [1] Wevers-de Boer K, et al. Ann Rheum Dis. 2012Sep;71(9):1472–7. Disclosure of Interest None declared

Background The diagnosis and treatment of neuropsychiatric systemic lupus erythematosus (NPSLE) is challenging due to the lack of a diagnostic gold standard and controlled trials. Immunosuppressive therapy is prescribed for immune-mediated NPSLE manifestations, despite little evidence supporting its effectivity. There is increasing evidence for the value of magnetization transfer imaging (MTI) in NPSLE. Recent research has demonstrated that white matter (WM) magnetic transfer ratio histogram peak height (MTR-HPH), a derived-MTI index, is a valuable radiological biomarker for the diagnosis and follow-up in inflammatory NPSLE.1 It remains unknown whether the changes in WM MTR-HPH also correlate with the change in health-related quality of life (QoL) in these patients. Objectives To analyse the correlation between change in WM MTR-HPH and change in QoL in different subsets of NPSLE (inflammatory, ischaemic, non-NPSLE). Methods Patients that visited the Leiden University Medical Centre (LUMC) NPSLE clinic between 2007 and 2015 were included in this study. The attribution process of NP events to SLE and one of its underlying pathogenic mechanisms (ischaemic or inflammatory) was established by multidisciplinary consensus. All patients underwent MRI examination at two different time points and filled in the Short-Form 36 (SF-36). Summary scores were deducted from the SF-36, leading to a Physical Component subscore (PCS) and a Mental Component subscore (MCS) for QoL. Spearman rank correlation coefficient (SR) was used to correlate WM MTR-HPH and the overall difference in change between visits in MCS and PCS. Data was analysed per patient and per event. Results A total of 15 patients (mean age 39.5±14.1 years, 93% female) were included. Thirty-one NPSLE events were present, of which 68% were inflammatory, 13% ischaemic and 19% non-NPSLE events. Average time between visits was 2.9±1.5 years. The per patient analysis showed statistical significant correlation between WM MTR-HPH and MCS change (SR=0.62; p=0.01) and no effect on PCS change (SR=0.09; p=0.76). The per event analysis showed a significant correlation between change in WM MTR-HPH and MCS in inflammatory events (SR=0.56; p=0.01), but not in ischaemic (p=0.20) or non-NPSLE events (p=0.65). No correlation was observed between change in WM MTR-HPH and PCS in any of the subsets (p=0.21, p=0.40 and p=0.91 respectively). Conclusions We are the first to demonstrate a correlation between a radiological biomarker and change in the mental component of QoL in inflammatory NPSLE patients. Our study supplies evidence for the use of immunosuppressive therapy in inflammatory NPSLE and supports the use of this radiological biomarker as an outcome measure for future trials in NPSLE. Reference [1] Magro-Checa C, Ecran E, Wolterbeek R, et al. Changes in White Matter Microstructure Suggest an Inflammatory Origin of Neuropsychiatric Systemic Lupus Erythematosus.Arthritis Rheumatol2016;68(8):1945–1954. Disclosure of Interest None declared

Background What is the optimal glucocorticoid (GC) bridging therapy with MTX monotherapy in early arthritis? Objectives To compare short term clinical efficacy of high and low dose GC tapering schedules with MTX monotherapy in 2 clinical trials in early rheumatoid arthritis (RA) and undifferentiated arthritis (UA) patients. Methods In tREACH, early RA and UA (arthritis in ≥1 joint(s), In IMPROVED RA and UA (arthritis in ≥1 joint and ≥1 other painful joint, Results Patients with a HDGC (n=610) had shorter symptom duration and higher HAQ, were less often seropositive (ACPA positive 56.0% vs 77.3%, RF positive 58.1% vs 65%) and more often had UA (20.3% vs 2.1%) than patients with a LDGC (n=97). Baseline DAS was comparable. At the first evaluation time point (median 3.06 (IQR 2.99–3.22) months in LDGC, 4.01. (3.8–4.17) in HDGC) DAS and HAQ had decreased significantly less after 3 months LDGC: DAS β (95% CI) 0.500 (0.276; 0.725), and HAQ 0.330 (0.189; 0.470) than after 4 months HDGC (figure 1). Compared to the HDGC patients, patients with the LDGC had a significantly lower chance of achieving DAS-remission 63.4% vs 28.9% (OR (95% CI) 0.215 (0.124; 0.373) and low disease activity 80.6% vs 55.7% ((OR (95% CI) 0.249 (0.143; 0.435)). Presence of ACPA was positively associated with achieving DAS-remission in the HDGC group, but not in the LDGC group. Per 100 patient years, 7.98 serious adverse events were reported in the HDGC and 23.4 in the LDGC (p=0.004). Hypertension, hyperglycemia (>7.8 mmol/L), gastrointestinal complaints and liverenzymes above normal were reported in similar frequencies across all groups. In patients with a LDGC more headaches, skin rashes, creatinine above normal range and any decrease in haematology blood counts were reported (data not shown). Conclusions In early arthritis patients, GC bridging therapy with prednisone 60 mg daily tapered in 7 weeks to and continued at 7.5 mg daily in combination with MTX monotherapy was associated with better clinical outcomes and without additional effects than prednisone 15 mg daily tapered to nil in 10 weeks in combination with MTX monotherapy, after correction for baseline age, gender, DAS, body mass index, presence of ACPA, presence of rheumatoid factor, symptom duration, and (in GEE) time from baseline. Disclosure of Interest J. van der Pol: None declared, E. Brilman: None declared, P. de Jong: None declared, A. Weel Grant/research support from: tREACH study was supported by an unrestricted grant from Pfizer bv. [0881–1 02 217]. Pfizer had no involvement in study design; in collection, analysis and interpretation of data; writing of the report and decision to submit for publication., J. Hazes: None declared, T. Huizinga: None declared, C. Allaart Grant/research support from: The work was supported by AbbVie during the first year of the IMPROVED study. Study design, data collection, trial management, data analysis and preparation of the manuscript were performed by the authors.

Background Previous reports on a window of opportunity in rheumatoid arthritis (RA) may be related to the use of slow acting c(onventional) s(ynthetic) DMARDs. We hypothesised that onset of action of therapy might influence whether there is a window of opportunity or whether ‘earlier is just better’. Objectives To investigate the association between symptom duration at treatment onset and the achievement of sustained drug free remission (sDFR) in early RA patients initiating therapy including fast acting prednisone or infliximab, compared to patients initiating csDMARD monotherapy. Methods We analysed the shape (hyperbolic or linear) of the association between symptom duration and achievement of sDFR (DAS Missing DAS were imputed using last observation carried forward. We performed Cox regression analyses with as outcome sDFR and as predictor symptom duration and compared the likelihood ratio tests of a linear model and a model with inclusion of natural cubic spline functions (resulting in a hyperbola), to investigate which model was a better fit for the data. Results In BeSt (n=469), IMPROVED (n=421) and METEOR (n=1653) 54, 110 and 10 patients who started with csDMARD and prednisone or anti-TNF combination therapy, and 53 in BeSt and 15 in METEOR who started with csDMARD monotherapy (no monotherapy in IMPROVED) achieved sDFR. A hyperbolic model did not show a better fit for the data than a linear model (for combination therapy in BeSt p=0.743, IMPROVED p=0.337, METEOR p=0.608, for csDMARD monotherapy in BeSt p=0.609, in METEOR p=0.758). Figure 1 shows the linear association between symptom duration and sDFR per study. These results indicate that the earlier treatment is started, the higher the likelihood of achieving sDFR. However, the data do not suggest that a hyperbolic relationship between treatment onset and outcome sDFR fit the data better. Conclusions Our data suggest that there is no evidence for a window of opportunity in early RA in 3 cohorts. This was not related to use of fast acting combination therapy including prednisone or anti-TNF instead of slow acting csDMARD monotherapy nor was it dependent on strict treatment to target in a clinical trial. It remains that earlier treatment initiation is better when aiming to achieve sDFR. Disclosure of Interest J. van der Pol: None declared, S. A. Bergstra: None declared, N. Riyazi: None declared, Y. Goekoop-Ruiterman: None declared, A. Chopra: None declared, P. Kerstens: None declared, W. Lems: None declared, R. Tsonaka: None declared, T. Huizinga Consultant for: UCB, BMS, Pfizer, Roche, Sanofi-Aventis and Boeringher from outside the submitted work., C. Allaart Grant/research support from: The IMPROVED study was designed by the investigators and financially supported during the first year of follow-up by AbbVie. The BeSt study was supported by the Dutch College of Health Insurances, with an additional grant from Schering-Plough BV and Centocor Inc.

Background: In rheumatoid arthritis (RA), the relationship between autoantibody status and treatment response to methotrexate remains unclear. As methotrexate is the most widely used anti-rheumatic drug in clinical practice, it would be important to know whether the presence of autoantibodies is associated with better treatment response, since patients may benefit from treatment tailored to “autoantibody status”. Objectives: We investigated the relationship between autoantibody status and remission in newly diagnosed RA-patients treated with first-line methotrexate. Methods: RA-patients initially treated with methotrexate were selected from an international observational database (METEOR). Patients were stratified into autoantibody-positive (rheumatoid factor (RF)- and/or anti-citrullinated-protein antibodies (ACPA)-positive) or -negative (RF- and ACPA- negative). The effect of autoantibody status on the chance of achieving remission within 3 to 6 months was analysed using Cox-proportional hazards regression. Results: Data from 1826 RA-patients were available for analysis. DAS remission was achieved in 17% (318/1,826). This was similar in autoantibody-positive (17% (282/1629)) and -negative patients (18% (36/197)). Hence, autoantibody positivity was not associated with remission (HR0.89, 95%CI 0.57;1.38). Similar findings were found when stratified for methotrexate monotherapy (HR0.75, 95%CI 0.41;1.37) or combination treatment (HR0.76, 95%CI 0.37;1.54). Good physical function (HAQ Conclusions: In conclusion, we found that autoantibody status was not associated with early remission in newly diagnosed RA-patients receiving methotrexate in real-world clinical practice. These results do not support the hypothesis that treatment should be tailored to “autoantibody status” when it comes to initiating methotrexate therapy as first-line anti-rheumatic treatment. Rather, our results indicate that that methotrexate is effective as primary anchor drug regardless of autoantibody status. Disclosure of Interest: None declared

Background Neutrophil extracellular traps (NETs) are auto-antigenic DNA strands and potentially give rise to SLE-specific autoantibodies that can deposit in glomeruli. It has been shown that autoantibodies can induce NETs, contributing to the vicious circle of immune activation in SLE. We hypothesised that eliminating autoantibodies can lead to decreased NET induction and thereby ameliorating disease in SLE. Therefore, we designed a proof-of-concept study to eliminate autoantibodies and NET formation through synergetic B-cell immunomodulation with rituximab and belimumab (RTX+BLM) in severe refractory SLE. Methods We treated patients with severe, refractory SLE in a phase 2 study with RTX+BLM. The primary endpoint assessed reduction of pathogenic autoantibodies and NET induction at 24 weeks. Anti-dsDNA autoantibodies were measured and high sensitivity FACS was performed to assess B-cell subsets. NET induction was measured with 3D confocal immunofluorescence microscopy. Results We included 16 patients with severe, refractory SLE of whom 13 had a renal flare. At 24 weeks we observed significant reductions in anti-dsDNA autoantibodies (p=0.0004). CD19 +B cells were depleted throughout the study (p=0.0002) while plasma cells (PCs) temporarily decreased but returned at week 24 despite persistent depletion of transitional B-cells. Taken together with the observed reductions of autoantibodies and stable total IgG and protective antibodies, there is no reconstitution of autoreactive PCs. Further, we observed excessive NET induction in all patients at baseline which was reduced after 24 weeks (p=0.0006). In vitro studies elucidated this resulted in reduction of immune complexes by RTX+BLM. Importantly, the beneficial immunological effects translated to amelioration of clinical disease activity: SLEDAI decreased from a median of 18 to 2 (p Conclusion The SynBiose study is the first to demonstrate that RTX+BLM ameliorated disease in patients with severe SLE in association with the reduction of pathogenic autoantibodies and immune complex-mediated NET induction. Therefore, RTX+BLM represents a novel treatment concept in SLE.

Background Aiming at rapid decrease of disease activity, there has been a trend to start with higher doses of methotrexate (MTX) in newly diagnosed rheumatoid arthritis (RA) patients, both as monotherapy and in combination with other antirheumatic drugs (DMARDs). We hypothesized that in combination with other very effective medication, there might be no additional benefit of high over low doses of MTX. Objectives To compare early clinical response to high versus low doses of MTX in mono- and combination therapy in DMARD naive early RA patients. Methods RA patients included in the observational international METEOR cohort with symptom duration ≤5 years, time between diagnosis and first visit ≤2 months, MTX prescribed as (part of) first treatment, no medication change within 3 to 6 months after treatment start and available outcome data on disease activity, were selected. Patients were divided into 4 medication groups: MTX monotherapy, MTX + synthetic (cs)DMARDs, MTX + oral glucocorticoid (+ possibly csDMARDs) or MTX + biologic (b)DMARDs (+ possibly csDMARDs). Missing data were imputed using multivariate normal imputation. MTX dose was dichotomized: low dose ≤10 mg/week; high dose ≥15 mg/week. A propensity score (PS) was calculated to adjust the relationship between MTX dose and outcome for potential confounding by indication. Linear mixed model analyses for DAS, DAS28, and HAQ were performed for each medication group, with MTX-dose and time (days between assessment visit and baseline assessment) as co-variates. Associations were adjusted for the PS. Random intercept and slope were used to account for irregular time intervals between visits. Results Patients who started on MTX monotherapy had lower baseline disease activity and fewer were erosive and autoantibody positive; other baseline characteristics were comparable between medication groups. The number of patients on combination therapy with bDMARDs was too small to perform analyses (26 visits in 11 patients). For patients starting on MTX monotherapy, MTX+csDMARDs or MTX+glucocorticoids, the PS-adjusted effects of MTX-dose (high vs low) on DAS, DAS28 and HAQ were small and not clinically meaningful. The unadjusted main associations between MTX-dose and outcomes were often in opposite direction and/or much larger than the PS adjusted associations, suggesting that confounding by indication indeed plays a role and that (at least some) correction was achieved by adjusting for the PS (table 1). Conclusions In a daily practice derived database in DMARD-naive early RA patients, we found no early clinical benefit of high over low initial MTX doses, neither for MTX monotherapy nor for combination therapy with MTX and csDMARDs or glucocorticoids. This seems to contradict a general trend over time to start higher MTX-doses. Disclosure of Interest None declared

Background Early identification of rheumatoid arthritis (RA) is important, because it allows early treatment initiation and is associated with better disease outcomes. In this perspective, the use of hand and foot MRI in the diagnostic process of rheumatoid arthritis (RA) has been advocated. Recent studies showed that MRI is helpful in predicting progression from clinically suspect arthralgia (CSA) to clinical arthritis, and from undifferentiated arthritis (UA) to RA. However, the diagnostic value of MRI is still undetermined. Most studies focussed on the sensitivity rather than the specificity of inflammation detected on MRI. It is known that symptom-free persons can also show inflammation on MRI. Consequently, it has been questioned if MRI-findings in symptom-free volunteers are relevant to consider as a reference when defining a “positive MRI”. Objectives To determine the value of considering MRI-findings in a control group for the predictive accuracy of MRI when defining a positive MRI. Methods 225 patients with CSA and 201 patients with UA underwent MRI of MCP-, wrist- and MTP-joints at baseline and were followed for 1 year on progression to arthritis and RA respectively. MRI was considered positive either if ≥1 joint showed inflammation (called “uncorrected definition”), or if ≥1 joint had inflammation that was present in Results By using MRI-data of symptom-free volunteers as reference, the specificity of MRI-detected inflammation increased from 22% to 56% in CSA-patients, and from 10% to 36% in UA-patients. The sensitivity was not affected; it was 88% and 85% in CSA-patients and 93% and 93% in UA-patients. The accuracy also increased, from 32% to 60% in CSA-patients and 22% to 44% in UA-patients. Conclusions The use of a reference population resulted in a substantial reduction of false-positive results, without affecting the sensitivity. This is of high importance because of the potential risks of false-positive MRI-results, for example in the setting of UA as a positive MRI-result may influence the decision to initiate disease modifying medication. Although a reference population is generally used in medicine for other tests to derive a definition of a positive test result, this is the first study demonstrating the value of a reference population to define a “positive MRI”. Disclosure of Interest None declared

Background Autoimmunity in Rheumatoid arthritis (RA) patients is characterized by a spectrum of anti-modified protein antibodies (AMPA) directed against post-translationally modified (PTM) proteins. The best-known AMPA in RA are anti-citrullinated protein antibodies (ACPA). Much less is known about the occurrence and aetiology of other AMPA responses in RA such as autoantibodies directed to malondialdehyde-acetaldehyde (MAA) adducts, acetylated antigens, and carbamylated proteins. Anti-carbamylated protein (anti-CarP) autoantibodies recognize carbamylated proteins containing a homocitrulline, a PTM structurally similar to citrulline. With the presence of various AMPA responses in RA, PTM proteins have been implicated in the breach of autoreactive B-cell tolerance leading to the formation of these autoantibodies. At present it is unkown how AMPA are generated and how autoreactive B-cell responses against PTM proteins are induced. Objectives To investigate how PTM proteins, more specifically carbamylated proteins, could contribute to a breach of B-cell tolerance. Methods Serum reactivity towards five different carbamylated proteins was determined for 160 RA-patients and 40 healthy individuals. Anti-CarP antibody cross-reactivity was studied by inhibition experiments. Mass spectrometry was performed to identify carbamylated self-proteins in human rheumatic and osteoarthritic joint tissue. Mice were immunized with carbamylated- or non-modified foreign (OVA) and self-antigens (mouse Albumin). Sera of immunized mice and monoclonal antibodies were analyzed for antigen reactivity. Results We show that anti-CarP antibodies in RA are highly cross-reactive towards multiple carbamylated proteins, including modified self- as well as modified non-self proteins. Immunization with carbamylated foreign proteins (Ca-OVA) induced a strong anti-CarP response against both carbamylated foreign- and self-proteins. Similar to murine serum anti-CarP antibodies, murine monoclonal anti-CarP antibodies were highly specific and cross-reactive to multiple carbamylated (auto)antigens. Although citrulline greatly resembles homocitrulline residues in structure, murine anti-CarP antibodies differ in antigen recognition profile from ACPA as they are able to discriminate between citrullinated and homocitrullinated forms of the same protein. Interestingly, we were able to identify carbamylated-albumin, in RA synovial tissue, indicating that albumin is present in carbamylated form locally in the inflamed joint. Conclusions Self-reactive AMPA-responses can be induced by exposure to foreign proteins containing PTM. Our findings show that autoreactive B-cell responses against PTM self proteins can be induced by exposure to PTM foreign proteins and provide new insights on the breach of autoreactive B-cell tolerance by foreign proteins. Disclosure of Interest None declared

Background The pathogenesis of systemic lupus erythematosus (SLE) is characterized by B-cell hyperactivity leading to autoreactive plasma cells (PCs) that produce pathogenic autoantibodies and contribute to onset and maintenance of SLE. Therefore, novel treatment strategies in SLE are aimed at targeting autoreactive PCs. Rituximab (RTX) is used as off-label treatment in SLE and depletes CD20+ B-cells effectively, but is unable to deplete CD20- PCs. Belimumab (BLM), an anti-BAFF (B-cell activating factor) antibody, demonstrated efficacy in SLE as add-on therapy and resulted in reduction of B-cells and PCs. Objectives Because RTX+BLM has potential to target autoreactive PCs, we designed an open-label, proof-of-concept study to assess the clinical efficacy and safety of RTX+BLM in severe, refractory SLE patients. Methods A phase 2 proof-of-concept study, the SynBioSe study, was set up to treat severe, serologically active and refractory SLE patients with RTX following BLM. The following endpoints were assessed at 24 weeks: a) clinical efficacy by SLEDAI; b) immunological effects on B-cells and PCs by high sensitivity flow cytometry, immunoglobulins and autoantibody levels, and c) safety parameters. Results The study included 11 severe, refractory SLE patients of which 10 had lupus nephritis and 1 patient had neuropsychiatric lupus with a median SLEDAI of 18 [range 8–29]. Treatment with RTX+BLM led to clinically significant improvement to a median SLEDAI score of 2 [0–13] (p=0.002). Low disease activity (SLEDAI 6 cells/L [range 21*10 6 -511x10 6 ] at screening to 5x10 6 [0–24x10 6 ] at 24 weeks, p=0.004), including transitional B-cells (from median 1.3x10 3 cells/L [1–1.3x10 4 ] at screening to 98.5 [0–3.4x10 3 ] at 24 weeks, p=NS). Importantly, total immunoglobulin levels only declined temporarily. The latter was further corroborated by transient reductions in CD3-CD38brCD27brCD20- PCs from median 1.6x10 6 cells/L [5.6x10 3 –1.1x10 7 ] to 1.5x10 5 cells/L [5.3x10 4 –1.3x10 7 ] at 12 weeks (p=NS). At 24 weeks, these PCs were restored to baseline levels (1.4x10 6 cells/L [9.2x10 4 –3x10 7 ]). Conclusions This is the first study to demonstrate that RTX+BLM effectively reduced disease activity in severe, refractory SLE without raising major safety issues, while reducing other immunosuppressant drugs. Autoreactive PCs were specifically targeted by RTX+BLM. Therefore, combination therapy of RTX+BLM is a promising strategy in severe SLE. Trial registration:ClinicalTrials.gov NCT02284984 Disclosure of Interest None declared

Background Mast cell numbers are increased in the rheumatoid arthritis joint. We have previously shown that mast cells can be activated by IgG-ACPA leading to the production of proinflammatory cytokines. However, not much is known about the resulting function when mast cells would repeatedly engage IgG, a likely scenario given the long life span of mast cells (up to a year) and the perpetual presence of IgG-ACPA in the joints. We have recently shown that mast cells triggered repeatedly through their Ig Fc epsilon receptor undergo a reprogramming of their responses (Suurmond et al. JACI, 2016 by expressing de-novo transcribed genes in the antigen presentation and pathogen defence response pathways. Objectives The aim of the current work was to determine whether mast cells show similar changes in their response mode following repeated interactions with IgG. Methods Human cord blood-derived mast cells were treated for 2 weeks with plate-bound IgG. The expression profile of naive or treated mast cells was measured through RNA sequencing, quantitative RT-PCR, flow cytometry. Protein secretion was measured with ELISA and Luminex assays. Metabolic changes were measured using HPLC mass-spectrometry. Results Similar to our previous work on Fc Epsilon receptor, we observe a dampening of the normal IgG responses with a set of novel genes upregulated. Interestingly, de-novo expressed genes consisted of DHCR7 and DHCR24, key enzymes in the cholesterol pathway. Pathway analysis confirms an enrichment of genes in this pathway following repeated IgG triggering. Preliminary data on metabolic profiling reveals a decrease in phospholipid levels in repeatedly activated mast cells. Conclusions Our study provides evidence that mast cells are reprogrammed upon repeated IgG triggering. In contrast to repeated Fc Epsilon Receptor triggering, different pathways are affected, implying stimulus-specific effects. Our work has important implications for the understanding the role of mast cells in rheumatoid arthritis. Disclosure of Interest None declared

Background Although antibody status has shown to improve clinical subsetting in Systemic sclerosis (SSc), it is far from perfect. For optimal clinical subsetting as well as for evaluating the possible pathogenic role of SSc specific antibodies, it is relevant to know to what extent clinical SSc phenotypes are determined by presence of these antibodies. Objectives To evaluate 1. if clinical relevant subsets of SSc patients are distinguishable using only clinical data, 2. how SSc specific autoantibodies are distributed among these subsets, and 3. whether adding antibody status to cluster analyses improves recognition of SSc subsets. Methods Using data from SSc patients of the Combined Care In Systemic Sclerosis (CCIS) cohort, Leiden University Medical Center, hierarchical clustering based on Ward Method was performed on the first obtained factor of principal component analysis of 7 organ systems (skin;lung;heart;kidney;muscle;vascular;gastro-intestinal) and time since non-Raynaud phenomenon. Clinical characteristics and prevalence of auto-antibodies within clusters was evaluated. We assessed whether adding autoantibody status as additional factor improved clinical subsetting. Results Of 407 SSc patients included, 371 patients (91%) fulfilled ACR/EULAR 2013 criteria. Prevalence of anti-centromere (ACA) was 37%, anti-topoisomerase (ATA) 24%, anti-RNAPIII 5%, anti-fibrillarin 4%, anti-Pm/Scl 5%. Cluster analysis identified clinically recognisable clusters of SSc patients based on absence of skin involvement (cluster 1), peripheral vascular involvement (cluster 2), fibrotic complications (cluster 4), and severe vascular complications (pulmonary arterial hypertension [PH], renal crises; cluster 5). Except for cluster 4, where ATA was dominant, in all clusters ACA was the most prevalent auto-antibody. No cluster associated with any of the more rare SSc specific auto-antibodies. Adding of auto-antibodies resulted in increased clinical overlap, with a frequency of PH between 6 – 8% and a frequency of digital ulcers between 24 – 39% in clusters 2,4 and 5. Conclusions Based on clinical data alone, relevant subgroups in SSc can be distinguished. Adding antibody status to cluster analyses increases overlap of clinical features between subgroups. These findings show that solely presence of SSc specific antibodies is of limited clinical relevance. For optimal risk stratification more complex serological findings as antibody titers might be additive. Disclosure of Interest None declared

Background Neutrophil extracellular traps (NETs) are extracellular, decondensed DNA strands covered with antimicrobial proteins that are part of the first-line defence against pathogens. However, in SLE, overall release of NETs is increased and degradation of NETs is impaired leading to a high amount of extracellular nuclear material, potentially leading to formation of SLE-specific antibodies. These pathogenic autoantibodies deposit in glomeruli in lupus nephritis (LN) and perpetuate autoimmunity by inducing more NETs. The present study hypothesized that combining anti-CD20 mediated B-cell depletion with BAFF (B-cell activating factor) inhibition can target autoreactive plasma cells and thereby effectively reduce pathogenic autoantibodies and NET induction in severe SLE. Objectives The present study aimed to investigate whether Rituximab (RTX) + Belimumab (BLM) affected pathogenic antibodies in relation to NET induction in severe refractory SLE. Methods As part of a phase 2 proof-of-concept study, the SynBioSe study, serum levels of anti-DNA autoantibodies were measured in severe, refractory SLE patients before and after treatment with RTX following BLM. Additionally, ex vivo NET induction was assessed before and after treatment with a novel highly sensitive method based on 3D confocal laser scanning microscopy. In this assay, healthy neutrophils are incubated with 10% serum of patients and healthy controls. Furthermore, we investigated whether NET induction was mediated by immune complexes. Results The study included 10 severe, refractory SLE patients with lupus nephritis and 1 patient with neuropsychiatric lupus. NET induction was found to be high at baseline with a median fold induction of 4.5 [range 2.6–11.7]. After 24 weeks, NET induction was significantly decreased (median fold NET induction of 1.6 [0.4–6.1], p=0.01). In addition, treatment with RTX+BLM led to significant reduction of anti-dsDNA antibodies at week 24 with a median of 35 IU/ml [range 10–374] compared to 120 [18–505] at baseline (p=0.012). Total immunoglobulin levels temporarily declined but returned to screening levels at week 24. NET induction correlated significantly with anti-dsDNA antibody levels (r=0.42, p=0.03) and with SLEDAI scores (r=0.53, p=0.003). Therefore, we examined whether the observed NET induction could be explained by circulating immune complexes (ICx). ICx were degraded by pre-incubating anti-dsDNA positive SLE sera with nuclease, resulting in a significant decrease in NET induction (median % decrease of 91.7 [range 67.6–98.1]). In addition, depletion of IgG from anti-dsDNA positive SLE sera resulted in significantly lower NET induction. Finally, immobilized IgG isolated from anti-dsDNA positive SLE sera, but not of control serum, resulted in significant NET induction. Conclusions Within refractory SLE patients, RTX + BLM resulted in concordant reductions in pathogenic anti-dsDNA antibodies and NET-inducing capacity. This study strongly suggests that NET induction in SLE is mediated by immune complexes, providing a possible explanation underpinning the clinical benefits of RTX+BLM in SLE. Trial registration:ClinicalTrials.gov NCT02284984 Disclosure of Interest None declared

Objective To evaluate three disease activity score (DAS) alternatives without the Ritchie articular index (RAI). To compare the use of patient global assessment (PGA) of disease activity versus global assessment of health (GH) in DAS, DAS alternatives and DAS28. Methods Data from the BeSt study were used, a treatment strategy trial in early rheumatoid arthritis patients aiming at a DAS ≤2.4. DAS alternatives were DAS 0–1, with the RAI (0–3) reduced to a no–yes (0–1) score, DAS tender joint count 53 (DAS TJC53), with a 0–1 TJC in 53 separate joints and DAS TJC44 in 44 joints. Correlation patterns, mean difference from original DAS, classification differences in disease activity level and patient percentages with radiological damage progression per level were determined for all scores. Results In the majority of patients the scores were equal and correlation was high. Mean difference with the DAS at year 1 was −0.03 for DAS 0–1, 0.18 for DAS TJC53 and 0.11 for DAS TJC44. Classification agreement between scores was high (κ year 1 0.76–0.98). Patient percentages with joint damage progression were similar for all scores. DAS, DAS alternative and DAS28 perform similarly using either PGA or GH. Conclusion DAS without the RAI perform comparably to the original DAS and may be chosen as alternatives. PGA can replace GH in the DAS, the alternatives and DAS28.

Objective To investigate the long-term clinical and radiographic disease course of hand osteoarthritis (OA) and determinants of outcome. Methods Clinical and radiographic measures were obtained at baseline and after 6 years in 289 patients with hand OA (mean age 59.5 years, 83.0% women). Clinical outcomes were self-reported pain and functional limitations assessed with the Australian/Canadian Osteoarthritis Hand Index (AUSCAN). Poor clinical outcome was defined as a follow-up score not fulfilling the Patient Acceptable Symptom State. Radiographic outcome was assessed by osteophytes and joint space narrowing (JSN) on standardised hand radiographs using the Osteoarthritis Research Society International (OARSI) atlas. Radiographic progression was defined as a change in osteophytes or JSN, above the smallest detectable change. Change in outcome measures was calculated and baseline determinants for poor clinical outcome and radiographic progression were assessed using logistic regression analysis. Results Clinical change showed great variation, with half of the population reporting deterioration. Poor outcome in pain was related to high levels of functional limitations and a high number of painful joints at baseline. Poor outcome on functional limitations was related to high baseline pain levels. Radiographic progression was present in 52.5% of patients and associated with high baseline levels of pain, nodes, osteophytes and the presence of erosive OA and nodal OA. Clinical change and radiographic progression were not related. Conclusions This study gives insight in the clinical and radiographic course of hand OA as well as determinants of outcome. These findings enable better patient information on prognosis. The relationship between clinical and radiographic outcome needs further investigation.

Rheumatoid arthritis (RA) is a systemic autoimmune disease involving inflammation of the joints. Among the autoantibodies described in RA, anticitrullinated protein antibodies (ACPAs) are highly specific and predictive for RA. In addition, ACPAs have been implicated in the pathogenesis of RA. However, a direct functional response of immune cells from ACPA + RA patients toward citrullinated proteins has not been demonstrated. In this study, we show that exposure to citrullinated antigens leads to activation of basophils from ACPA + RA patients within 20 minutes. This was not observed after exposure of basophils to noncitrullinated control antigens or after stimulation of basophils from ACPA − RA patients and healthy controls. Basophil activation was correlated with the binding of citrullinated proteins to basophils. Furthermore, serum from ACPA + RA patients in contrast to that from ACPA − RA patients could specifically sensitize human FcεRI expressing rat basophil cells (RBL), enabling activation by citrullinated proteins. Mast cell degranulation products such as histamine levels were enhanced in synovial fluid of ACPA + RA patients as compared with ACPA − RA and osteoarthritis patients. In addition, histamine levels in synovial fluid from ACPA + RA patients correlated with IgE levels, suggesting degranulation of mast cells by cross-linking IgE. Immunohistochemistry on synovial biopsies demonstrated an increased number of degranulated CD117 + mast cells in ACPA + RA patients; IgE and FcεRI expression in synovial mast cells from ACPA + RA patients was increased. In conclusion, our results show an immunological response of immune cells from ACPA + RA patients in a citrulline-specific manner. Moreover, these data indicate a role for IgE-ACPAs and FcεRI-positive cells in the pathogenesis of RA.

Objectives: Inflammation may contribute to progression of knee osteoarthritis (OA). Therefore, we investigated whether innate differences in the inflammatory response regarding cytokine production were associated with radiological progression of knee OA. Methods: Symptomatic patients with knee OA (n = 89) were included. Standardised posteroanterior knee radiographs were obtained at baseline and after 24 months. Medial and lateral tibiofemoral joint space narrowing (JSN) was graded with the Altman atlas. Radiological progression was defined as an increase of at least one score in JSN total scores. Whole blood samples were stimulated with lipopolysaccharide (LPS) (10 ng/ml). Relative risks (RR) with 95% CIs of OA progression in relation to quartiles of innate ex vivo production of interleukin (IL)1β, tumour necrosis factor (TNF)α, IL1 receptor antagonist (Ra) and IL10 were calculated. Results: Progression of JSN was present in 29 (33.7%) of 86 followed patients after 2 years. Patients in the highest quartile of TNFα production had a sixfold increased risk of JSN progression (age, sex and body mass index adjusted RR 6.1, 95% CI 1.4 to 9.8) and patients in the highest quartile of IL10 production had a fourfold increased risk of JSN progression (age, sex and body mass index adjusted RR 4.3, 95% CI 1.7 to 6.2), both in comparison with those patients in the lowest quartile. No significant associations were found between variations in IL1β and IL1Ra production and JSN progression. Conclusion: The innate capacity to produce TNFα and IL10 upon LPS stimulation is associated with radiological progression of knee OA, even over a relatively short follow-up period of 2 years.

Introduction The efficacy of the immune response upon vaccination in patients treated with anti-tumor necrosis factor-alpha (anti-TNF) with or without methotrexate is the subject of debate. We studied the effect of immunosuppressive treatment, including anti-TNF and methotrexate, on the response to pneumococcal polysaccharide (PPS) vaccine. Methods Fifty-two patients treated with immunosuppressives including anti-TNF (anti-TNF group), 41 patients given a similar immunosuppressive regimen without anti-TNF (no anti-TNF group), and 18 healthy controls were vaccinated with a 23 valent PPS vaccine. The percentage of patients treated with methotrexate in the anti-TNF and no anti-TNF group was 65% and 76%, respectively. Antibodies against four of the vaccine antigens (PPS 6B, 9V, 19F and 23F) were measured before and 4 weeks after vaccination. The primary outcome was the response rate, defined as the percentage with a postvaccination titer 0.35 μg/ml in combination with at least a twofold increase in antibody titer. The protection rate was defined as a postvaccination titer ≥0.35 μg/ml. Results The use of methotrexate was the strongest predictor of impaired vaccination outcome. Anti-TNF caused an additional immunosuppressive effect in the presence of methotrexate, leading to the lowest response percentages in patients using the combination of these two drugs. The underlying disease, other immunosuppressives such as prednisone or type of anti-TNF agent used did not influence vaccination outcome. Conclusions Patients who were treated with the combination of methotrexate and anti-TNF demonstrated a significantly impaired immune response following pneumococcal polysaccharide vaccination as compared to patients treated with either methotrexate or anti-TNF only or immunosuppressives excluding these two compounds.

Obesity is a state of chronic low-grade inflammation that predisposes people to several diseases and that is increasingly prevalent. Rheumatoid arthritis (RA) is marked by the presence of proinflammatory cytokines and, in general, the presence of high levels of inflammatory markers is associated with a severe disease course and joint damage.To evaluate prospectively (a) whether obesity is a risk factor for the development of RA and (b) whether the body mass index (BMI) is associated with the amount of joint destruction in early RA after 3 years' follow-up.In a cohort of 570 patients with undifferentiated arthritis, the relation between the BMI and the development of RA during 1 year of follow-up was assessed. In a cohort of 488 patients with early RA the correlation between the BMI and degree of radiological joint destruction (Sharp-van der Heijde score) after 3 years of follow-up was determined. The findings were replicated in an independent cohort of 247 patients with early RA.Obesity did not influence the likelihood of developing RA. In both RA cohorts, the BMI was inversely correlated with the Sharp-van der Heijde score after 3 years' follow-up (r = -0.15, p = 0.025 for the Leiden EAC and r = -0.27, p0.001 for the replication cohort). Linear regression analyses in both cohorts showed that the BMI was independently and inversely associated with the level of joint destruction in anti-CCP-positive patients with RA, but not in anti-CCP-negative patients.A high BMI is associated with a less severe disease outcome in anti-CCP-positive patients with RA.

Background: Human leucocyte antigen is the only genetic risk factor for rheumatoid arthritis (RA) that has been consistently observed in different populations. A number of other genes such as PTPN22 and PADI4 showed population-specific association with RA susceptibility. Recently, Fc receptor-like 3 (FCRL3) gene was found to be associated with RA susceptibility in Japanese, but with conflicting results in other populations. Objective: To investigate the association of FCRL3 polymorphism with RA susceptibility and severity in Dutch Caucasian patients with RA, as well as to perform a meta-analysis to reveal the contribution of this gene to RA susceptibility. Methods: A total of 931 Dutch RA cases and 570 unrelated Dutch controls were genotyped for four FCRL3 single-nucleotide polymorphisms (SNPs). Genotyping was performed using the MassArray matrix-assisted laser desorption ionisation-time-of-flight mass spectrometry. Association of the FCRL3 SNPs with susceptibility to RA was examined by single-marker, carrier and haplotype analysis. Results: Carrier analysis of the SNP (rs7528684) revealed the association of CC genotype with a higher risk of developing RA as compared with TT and TC carriers (p = 0.039 and OR = 1.31). There was no significant difference in the genotype and allele frequencies of all investigated SNPs between cases and controls. Meta-analysis of all studies comparing 9467 individuals showed that the OR for the CC genotype to develop RA was 1.2 and the p value Conclusion: A promoter polymorphism of FCRL3 (rs7528684) is associated with an increased risk of developing RA in Dutch Caucasians, suggesting that this association is relevant for RA in both Japanese and Caucasian populations.

(1) To assess innate ex vivo production of interleukin 1beta (IL1beta) and interleukin 1 receptor antagonist (IL1Ra) in patients with recent-onset rheumatoid arthritis (RA) as compared with healthy controls; (2) to assess the association of ex vivo IL1beta and IL1Ra production with progression of joint damage in RA; (3) to determine whether differences in ex vivo IL1beta production are explained by distribution of the IL1beta single nucleotide polymorphism C-511T.Levels of IL1beta and IL1Ra (measured by ELISA after whole-blood stimulation with lipopolysaccharide) and distribution of IL1beta C-511T were compared in 76 patients with recent-onset RA who had received no disease-modifying antirheumatic drugs (DMARDs), and 63 healthy controls. ORs for RA based on ex vivo IL1beta and IL1Ra production were calculated. Association of ex vivo IL1beta and IL1Ra production with progression of joint damage (Sharp-van der Heijde score over 2 years) was determined by linear regression with correction for baseline characteristics.Patients with recent-onset RA showed lower ex vivo IL1beta and higher ex vivo IL1Ra production than healthy controls (p0.001), with ORs for RA of 2.4 (95% CI 1.2 to 4.9) for low IL1beta-producers and 7.6 (95% CI 3.2 to 18.0) for high IL1Ra-producers. High ex vivo IL1Ra production was associated with progression of joint damage (p = 0.01). The IL1beta C-511T genotype distribution was not significantly different between patients and controls.Patients with recent-onset RA had decreased ex vivo IL1beta production and increased ex vivo IL1Ra production compared with controls. Ex vivo IL1Ra production is an independent predictor of progression of joint damage in recent-onset RA.

The care of patients with rheumatoid arthritis (RA) has been revolutionized since the 1990s. Strict monitoring and disease control based on measurement of signs and symptoms towards a target of low disease activity have improved outcome of patients enormously. As a result of treatment strategies based upon individualized measurement of disease activity, the clinical view of RA has changed from a destructive autoimmune disease (with a median joint damage of >10 Sharp units per year) to a condition in which significant damage can be prevented in the majority of patients. Moreover, a large number of targeted therapies (tumour necrosis factor, IL6, CD80/CD86 and CD20 inhibitors) have become available to better treat the underlying disease process. However, identification of the underlying pathways that drive the disease process in an individual patient has been relatively unsuccessful, implying that no predictive factors have been identified to guide the choice of a specific treatment. Distinct subsets of RA patients have been identified, based on the presence or absence of anticitrullinated protein antibodies (ACPAs). These two subsets are associated with different environmental and genetic risk factors, histology and disease outcome (a more destructive disease course with more persistent joint inflammation is observed when ACPAs are present). Therefore, it is recommended that treatment should be guided towards a more consistently low level of disease activity in the presence of ACPAs than in the absence of the antibodies.

Showing genetic variants in relation to achieving DMARD-free sustained remission in ACPA-positive and ACPA-negative RA patients from the Leiden EAC cohort. SE in ACPA-positive: HR per SE allele = 0.92 (95 % CI = 0.42–2.03). SE in ACPA-negative: HR per SE allele = 0.89 (95 % CI = 0.63–1.25). rs2104286 (IL2RA) in ACPA-positive: HR per minor allele = 1.82 (95 % CI = 0.88–3.77). rs2104286 (IL2RA) in ACPA-negative: HR per minor allele = 1.41 (95 % CI = 1.05–1.89). All analyses were adjusted for age, gender, and inclusion period (as proxy for treatment strategy). Note that the y axes of the ACPA-positive and ACPA-negative subgroups are different. (PDF 218 kb)

Showing SE alleles in HLA-DRB1 in relation to achieving DMARD-free sustained remission in RA patients in the Leiden EAC cohort. SE alleles were significantly associated with achieving DMARD-free sustained remission in 616 RA patients with HLA-DRB1 genotyping data (p = 2.72 × 10−4). The HR per SE allele for achieving remission was 0.57 (95 % CI = 0.42–0.77). The analysis was adjusted for age, gender, and inclusion period (as proxy for treatment strategy). (PDF 52 kb)

Objectives: To study the gene–environment interaction of tobacco exposure and shared epitope on autoantibodies in patients with rheumatoid arthritis and undifferentiated arthritis. Methods: From incident cases of arthritis (n = 1305), patients who did not fulfil any classification criteria (undifferentiated arthritis (n = 486)) and those who fulfilled the American College of Rheumatology criteria for rheumatoid arthritis (n = 407) were identified. IgM rheumatoid factor (RF), anti-cyclic-citrullinated peptide (CCP) antibodies, and HLA-DRB1 alleles were determined. Results: In rheumatoid arthritis, an interaction was found between tobacco exposure and shared epitope for the presence of anti-CCP antibodies, as the odds ratio for anti-CCP antibodies in patients having both tobacco exposure (TE) and shared epitope (SE) was higher than the summed odds ratios of patients having only tobacco exposure or shared epitope (odds ratios: TE+/SE−, 1.07; TE−/SE+, 2.49; and TE+/SE+, 5.27—all relative to TE−/SE−). A similar effect was found for RF, but stratification showed that the interaction primarily associated with the anti-CCP antibody response. In patients with undifferentiated arthritis at two weeks, or with persistent undifferentiated arthritis after one year, no interaction between tobacco exposure and shared epitope was observed for the presence of autoantibodies. Conclusions: Tobacco exposure increases the risk factor for anti-CCP antibodies only in shared epitope positive patients with rheumatoid arthritis. The gene–environment interaction between smoking and shared epitope leading to autoantibodies is specific for rheumatoid arthritis and is not observed in undifferentiated arthritis.

Objective. To investigate the possible association of the mannose binding lectin (MBL) pathway of complement activation with different disease parameters and disease activity in patients with systemic lupus erythematosus (SLE). Methods. MBL genotype, MBL serum concentration, MBL complex activity and MBL pathway activity were assessed in 53 patients. The activity of the MBL–MASP complex was assessed on the basis of its ability to activate exogenous C4. For MBL pathway activity the formation of the terminal complex of complement activation (C5b-9) was measured. Results were analysed in relation to clinical variables and autoantibody profiles in these patients. Results. MBL complex activity and MBL pathway activity were both reduced in patients carrying MBL variant alleles. Anticardiolipin and anti-C1q autoantibodies were observed significantly more frequently in patients with MBL variant alleles. Furthermore, the presence of these autoantibodies was associated with a decreased MBL concentration and function. In contrast, anti-MBL autoantibodies were not found in patients with MBL variant alleles, possibly related to impaired binding of variant MBL to apoptotic material. Conclusion. In patients with SLE, a reduced functional activity of the MBL pathway of complement, in relation to expression of MBL variant alleles, is associated with increased levels of autoantibodies against cardiolipin and C1q, but not against MBL. We hypothesize that an enhanced production of autoantibodies may be related to disturbed clearance of apoptotic material due to impaired MBL function.

Objective To investigate whether there is an association between HLA class II and distal interphalangeal osteoarthritis (DIP OA). Methods The study group consisted of consecutive patients with and without DIP OA aged between 40 and 70 years. DIP OA was diagnosed by radiology. These patients were referred to an "Early Arthritis Clinic" (EAC) with different types of arthritis at an early stage. Patients with rheumatoid arthritis, systemic lupus erythematosus, spondyloarthropathies, and psoriatic arthritis were excluded for the purpose of this study. DNA typing for HLA-DR and x ray examination of the hands were performed at enrollment in the EAC. To establish whether the study group was representative of the Dutch population, a population based study in Zoetermeer (n=3243) for the prevalence of DIP OA and blood donors in the Leiden area (n=2400) for the HLA-DR antigen frequencies were used as references. Results Fifty five patients (33%) of the total study group (n=166) had DIP OA. The prevalence of DIP OA and frequency of the HLA-DR alleles were similar to those of the two reference groups. Within the study group an association between DIP OA and HLA-DR2 and DR4 with respectively odds ratios of 2.4 (95% confidence interval (CI) 1.1 to 5.0) and 0.3 (95% CI 0.1 to 0.7) was found. No association was found between other HLA-DR alleles and DIP OA. Conclusion The study group is a representative sample of the Dutch population. The HLA-DR2 allele was more common in patients with DIP OA. Furthermore, an inverse relation was observed between DIP OA and HLA-DR4. The results confirm findings from other investigations implicating HLA-DR2 as a risk factor in the development of DIP OA.

Background: Matrix metalloproteinases (MMPs) have a pivotal role in the destruction of cartilage in rheumatoid arthritis (RA), which is mediated by the fibroblast-like synoviocytes (FLS). Objective: To examine the in vitro invasiveness of synoviocytes obtained from inflamed joints of patients with arthritis in relation to the expression of MMP 1–14, 17, 19, cathepsin-K, the tissue inhibitors of matrix metalloproteinases TIMP-1 and TIMP-2 by FLS. Methods: FLS were derived from 56 patients (30 with RA, 17 with osteoarthritis (OA), and nine with avascular necrosis (AVN)). Invasive growth of FLS through an artificial matrix (Matrigel) was measured in a transwell system. The number of cells that migrated through the matrix were counted. Proliferation rate was determined by counting the FLS after seven days of culturing. Expression of MMPs, cathepsin-K and TIMPs was investigated with reverse transcriptase-polymerase chain reaction and related to the expression of a household gene, s-actin. Results: FLS from RA showed greater invasive growth than FLS from OA and AVN. The median number of cells that grew through the matrix membrane was 4788 for RA, significantly higher than the number for OA, 1875 (p

Objective To investigate the association between baseline serum adipokines levels—leptin, adiponectin and resistin—and long-term progression of hand osteoarthritis (HOA). Methods Baseline and 6-year radiographs of 164 patients (mean age 60 years, 81% women) with HOA (defined as a Kellgren and Lawrence score ≥2 in at least two hand joints) were assessed for joint space narrowing (JSN) in 32 hand joints using the Osteoarthritis Research Society International atlas. Progression was defined as a change in the sum of the JSN score above the smallest detectable change of 2, reflecting change above measurement error. Serum adipokines were measured at baseline and patients were categorised by adipokine tertiles. RRs (and 95% CI) of HOA progression for patients in the second and third tertiles were calculated relative to the first tertile, using generalised estimating equations. Adjustments were made for age, sex and body mass index. Results Patients in the two highest tertiles of adiponectin had a decreased risk of 70% (RR=0.3 (0.2 to 0.7)) for HOA progression in comparison with patients in the lowest tertile. Leptin and resistin levels were not associated with progression. Conclusion Adiponectin levels are associated with progression of HOA, suggesting that adiponectin may be involved in the pathophysiology of OA.

Objective.To determine whether a multibiomarker disease activity (MBDA) score predicts radiographic damage progression in the subsequent year in patients with early rheumatoid arthritis.Methods.There were 180 serum samples available in the BeSt study (trial numbers NTR262, NTR 265): 91 at baseline (84 with radiographs available) and 89 at 1-year followup (81 with radiographs available). Radiographs were assessed using the Sharp/van der Heijde Score (SvdH). Twelve serum biomarkers were measured to determine MBDA scores using a validated algorithm. Receiver-operating curves and Poisson regression analyses were performed, with Disease Activity Score (DAS) and MBDA score as independent variables, and radiographic progression as dependent variable.Results.At baseline, MBDA scores discriminated more between patients who developed radiographic progression (increase in SvdH ≥ 5 points) and patients who did not [area under the curve (AUC) 0.767, 95% CI 0.639–0.896] than did DAS (AUC 0.521, 95% CI 0.358–0.684). At 1 year, MBDA score had an AUC of 0.691 (95% CI 0.453–0.929) and DAS had an AUC of 0.649 (95% CI 0.417–0.880). Adjusted for anticitrullinated protein antibody status and DAS, higher MBDA scores were associated with an increased risk for SvdH progression [relative risk (RR) 1.039, 95% CI 1.018–1.059 for baseline MBDA score; 1.037, 95% CI 1.009–1.065 for Year 1 MBDA score]. Categorized high MBDA scores were also correlated with SvdH progression (RR for high MBDA score at baseline 3.7; low or moderate MBDA score as reference). At 1 year, high MBDA score gave a RR of 4.6 compared to low MBDA score.Conclusion.MBDA scores predict radiographic damage progression at baseline and during disease course.

Treatment of patients with rheumatoid arthritis (RA) is rarely personalized, since predictors of disease course are lacking. The severity of RA can be measured objectively by radiographic progression. The most reliable way to measure radiographic progression is in a longitudinal cohort with serial time points, scoring on a quantitative scale, with a validated scoring method and trained readers. Current models used to predict radiographic progression are based on C-reactive protein and anti-citrullinated protein antibodies. Other biomarkers could increase the prognostic ability of these models. In this review, we evaluated the published (and partly nonpublished) data on genetic, serologic, and imaging biomarkers for the severity of joint destruction in RA. We evaluated variants in 10 genes (CD40, IL2RA, IL4R, IL15, OPG, DKK1, SOST, GRZB, MMP9, and SPAG16). In 5 variants (IL2RA, DKK1, GRZB, MMP9, and SPAG16), we found evidence of an association at the functional level. We evaluated several serological biomarkers, namely, autoantibodies (RF, ACPA, anti-CarP), markers related to inflammation (ESR, CRP), and proteinases or components of the extracellular matrix of bone and cartilage (MMP3, CTX-I, CTX-II, COMP, TIMP1, PYD, RANKL/OPG, CXCL13). Finally, we evaluated markers that can be visualized by ultrasound or MRI, including erosions, bone marrow edema, synovitis, and tenosynovitis. Several studies showed that bone marrow edema and synovitis on MRI are robust predictors of radiographic progression. Some studies showed that inflammation detected with ultrasound predicted radiographic progression. Future studies will reveal whether adding and combining all these different biomarkers will increase the accuracy of risk models predicting radiographic progression in RA.

OBJECTIVE—Treatment of patients with systemic lupus erythematosus (SLE) often implies strong drugs with possibly serious side effects. Thus there is a need for new immunosuppressive treatments. Long wave ultraviolet A (UVA-1) cold light therapy is an anti-inflammatory, immunomodulatory treatment with a possible systemic effect and few side effects. In the current study low dose UVA-1 cold light treatment was tested to determine whether it reduces disease activity in SLE. METHODS—Eleven patients with SLE were treated with UVA-1 cold light treatment and a placebo light treatment in a double blind, placebo controlled, crossover study. In two consecutive 12 week periods the patients were treated in the first three weeks with UVA-1 and placebo treatment or vice versa. The primary variables were the SLE Disease Activity Index (SLEDAI) and SLE Activity Measure (SLAM). RESULTS—The mean SLAM and SLEDAI showed a significant decrease of 30.4% (p=0.0005) and 37.9% (p=0.016) respectively after three weeks of UVA-1 and a non-significant decline of 9.3% (p=0.43) and 12.2% (p=0.54) respectively after three weeks of placebo treatment. In this small trial the difference in reduction of the disease activity indices during UVA-1 compared with during placebo treatment failed to reach the conventional border of significance (p=0.07). The total score of quality of life measure RAND-36 did not improve significantly, but the subscore for vitality did improve. CONCLUSION—Low dose UVA-1 cold light treatment was strongly suggestive of lowering disease activity in this double blind placebo controlled study, and no side effects occurred.