Characteristics of pulmonary cryptococcosis in patients with rheumatoid arthritis

Background and objectiveA high frequency of infections complicating rheumatoid arthritis (RA) has been reported due to the immunomodulatory effect of RA or to agents with immunosuppressive effects used in its treatment. We aimed to assess clinical and radiological characteristics of pulmonary cryptococcosis in patients with and without RA.MethodsWe retrospectively reviewed the medical records of 52 patients with pulmonary cryptococcosis and divided them into two groups, those with RA and without RA, and compared clinical characteristics and radiological findings between them.ResultsEleven (21.2%) of the 52 patients had RA. Median follow-up periods were 51.2 (range: 1.1–258.7) months for patients with RA and 19.1 (range: 0.63–246.9) months for patients without RA. Among the patients with RA, 81.8% were women, with a mean age of 68.1 years. Female sex and respiratory comorbidities were significantly more frequent in patients with RA than in patients without RA. Frequencies of concomitant cryptococcal meningitis and respiratory failure were not different between the groups. There were no significant differences in frequency of any radiological findings, locations and number between the two groups. Among patients with RA, all but one responded well to antifungal treatment. During the antifungal treatment course, one (9.1%) patient with RA died of cryptococcosis. Despite continuing antirheumatic drugs, no patients had recurrence of pulmonary cryptococcosis during follow-up.ConclusionOther than some differences in background, there were no clinical, radiological or prognostic differences between the patients with and without RA with pulmonary cryptococcosis. The administration of antirheumatic therapy had no negative effect on the clinical course of antifungal treatment.

Antirheumatic therapy is not associated with changes in circulating N-terminal pro-brain natriuretic peptide levels in patients with autoimmune arthritis

Background Patients with autoimmune arthritis (AA) are at increased risk for impaired cardiac function and heart failure. This may be partly due to the effect of inflammation in heart function. The impact of antirheumatic drugs on cardiac dysfunction in AA remains controversial. Therefore, we aimed to examine effects of antirheumatic treatment on serum N-terminal pro-brain natriuretic peptide (NT-proBNP) in AA patients and its relationship to inflammatory markers. Methods We examined 115 patients with AA (64 rheumatoid arthritis (RA), 31 psoriatic arthritis and 20 ankylosis spondylitis) starting with methotrexate (MTX) monotherapy or tumor necrosis factor inhibitors (TNFi) with or without MTX co-medication. NT-proBNP (measured in serum by ECLIA from Roche Diagnostics), and other clinical and laboratory parameters were evaluated at baseline, after 6 weeks and 6 months of treatment. Results NT-proBNP levels did not change significantly after 6 weeks and 6 months of antirheumatic therapy (pbaseline-6weeks = 0.939; pbaseline-6months = 0.485), although there was a modest improvement from 6 weeks to 6 months in the MTX only treatment group (median difference = -18.2 [95% CI = -32.3 to -4.06], p = 0.013). There was no difference in the effects of MTX monotherapy and TNFi regimen on NT-proBNP levels. The changes in NT-proBNP after antirheumatic treatment positively correlated with changes in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Baseline NT-proBNP levels were related to baseline CRP and ESR levels, and some other established markers of disease activities in crude analyses. Conclusion Circulating levels of NT-proBNP were related to established inflammatory markers at baseline, and the changes in NT-proBNP after antirheumatic treatment were positively related to these markers. Nevertheless, antirheumatic therapy did not seem to affect NT-proBNP levels compared to baseline, even though inflammatory markers significantly improved.

Association of biological antirheumatic therapy with risk for type 2 diabetes: a retrospective cohort study in incident rheumatoid arthritis

ObjectiveTo explore possible associations of treatment with biological disease-modifying antirheumatic drugs (bDMARDs), including T-cell-based and interleukin-6 inhibition (IL-6i)-based therapies, and the risk for type 2 diabetes mellitus (T2DM) in patients with rheumatoid arthritis (RA).Study design, setting and participantsFive treatment groups were selected from a United States Electronic Medical Records database of 283 756 patients with RA (mean follow-up, 5 years): never received bDMARD (No bDMARD, n=125 337), tumour necrosis factor inhibitors (TNFi, n=34 873), IL-6i (n=1884), T-cell inhibitors (n=5935) and IL-6i+T cell inhibitor abatacept (n=1213). Probability and risk for T2DM were estimated with adjustment for relevant confounders.ResultsIn the cohort of 169 242 patients with a mean 4.5 years of follow-up and a mean 641 200 person years of follow-up, the adjusted probability of developing T2DM was significantly lower in the IL-6i (probability, 1%; 95% CI 0.6 to 2.0), T-cell inhibitor (probability, 3%; 95% CI 2.3 to 3.3) and IL-6i+T cell inhibitor (probability, 2%; 95% CI 0.1 to 2.9) groups than in the No bDMARD (probability, 5%; 95% CI 4.6 to 4.9) and TNFi (probability, 4%; 95% CI 3.7 to 4.7) groups. Compared with No bDMARD, the IL-6i and IL-6i+T cell inhibitor groups had 37% (95% CI of HR 0.42 to 0.96) and 34% (95% CI of HR 0.46 to 0.93) significantly lower risk for T2DM, respectively; there was no significant difference in risk in the TNFi (HR 0.99; 95% CI 0.93 to 1.06) and T-cell inhibitor (HR 0.96; 95% CI 0.82 to 1.12) groups.ConclusionsTreatment with IL-6i, with or without T-cell inhibitors, was associated with reduced risk for T2DM compared with TNFi or No bDMARDs; a less pronounced association was observed for the T-cell inhibitor abatacept.

AB0257 IMPACT OF CONVENTIONAL ANTIRHEUMATIC TREATMENT ON CARDIOVASCULAR RISK IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:Cardiovascular diseases (CVD) are the most common and socially significant comorbidities and the main cause of premature mortality in rheumatoid arthritis (RA). Appropriate RA therapy should not only suppress RA activity, but also reduce CVD risk.Objectives:To evaluate CVD risk and analyze its association with the use of conventional therapy in RA patients (pts).Methods:The study included 100 pts with RA (92 women and 8 men) aged 30 to 60 without established CVD. The median age was 49.5 [44.5;53] years, duration of RA was 144 [60;240] months, DAS28 was 4.4 [3.3;5.3] points. Eighty six RA pts (86%) treated with disease-modifying antirheumatic drugs (DMARDs) (methotrexate, n=55; leflunomide, n=12; hydroxychloroquine, n=8; sulfasalazine, n=11), including 33 pts (33%) in combination with glucocorticoids (GCs). Fourteen pts (14%) received monotherapy with GCs. Pts were divided into three treatment groups: DMARDs group, n=53; GCs group, n=14; DMARDs+GCs group, n=33. CVD risk was calculated with ASSIGN, QRISK3, and ERS-RA scales.Results:No differences were found between the groups when calculating CVD risk using ASSIGN (table 1). Estimated CVD risk by QRISK3 was lower in DMARDs group (4.9 [3.0; 7.7]) than in DMARDs+GCs group (7.1 [4.1; 13.6], p<0.05). High CVD risk on the ERS-RA scale was determined less frequently (13%) and median CVD risk was lower in DMARDs group (4.2 [2.2; 5.4]) than in GCs group (57%; 8.9 [4.8; 11.7], p<0.01) and DMARDs+GCs group (39%; 6.6 [3; 9.3], p<0.05, respectively). In DMARDs group, significant differences in CVD risk by ERS-RA were found in pts treated with hydroxychloroquine (2 [1.4; 5.8]) and leflunomid (6.2 [2.8; 12.3], p<0.05).Conclusion:RA pts treated with DMARDs have a reduced risk for CVD than pts treated with GCs or a combination of DMARDs and GCs. GCs significantly increase CVD risk. To clarify the impact of hydroxychloroquine and leflunomid on CVD risk, a study on a larger number of pts is required.Table 1.The impact of conventional antirheumatic therapy on CVD risk.TreatmentASSIGNQRISK3ERS-RAHigh CVD risk, %median[25-75 percentiles]High CVD risk,%median[25-75 percentiles]High CVD risk,%median[25-75 percentiles]DMARDs, n=53611 [6.5;14]24.9 [3;7.7] v13*v4.2 [2.2;5.4] *vGCs, n=1479.5 [7;13]76.6 [4.4;15.8]57*8.9 [4.8;11.7] *DMARDs+GCs, n=331510 [5;13.5]97.1 [4.1;13.6] v39v6.6 [3;9.3] vNote: * - p<0.01 between pts receiving DMARDs and GCs; v - p<0.05 between pts receiving DMARDs and DMARDs+GCs.Disclosure of Interests:None declared

AB0307 IS THERE ANY INFLUENCE OF THE ANTIRHEUMATIC THERAPY ON ECHOCARDIOGRAPHIC FINDINGS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS?

Background:Cardiovascular diseases are becoming the leading cause of death among SLE patients due to increasing life-spans. Transthoracic echocardiography (TTE) is a routine and widely available modality in everyday clinical practice useful to identify specific pathological cardiac changes and predictors of heart failure.Objectives:The goal was to identify potential abnormalities in the TTE findings in SLE patients, with and without antirheumatic therapy.Methods:This is a prospective cross-sectional study including 91pts (91% females, aged 32[28-41]years (median [interquartile range 25%-75%]) with SLE (SLICC 2012 criteria). All patients were divided into 2 groups: the 1st group was composed of “untreated” patients and the 2nd – of patients receiving antirheumatic therapy. The 1st group included 43pts (93% females) aged 31[27–40]years who were not receiving steroids, immunosuppressants and biological agents at the time of enrollment, 5(12%) of them were on hydroxychloroquine (HCQ) therapy 200 mg/day. The 2nd group is represented by 48pts (89% females) with median age 34[28-45]years. Out of them 47(98%) patients were on prednisone therapy at 10[8-15]mg/day, 10(21%)- on cyclophosphamide, 6(13%)-azathioprine, 4(8%)-mycophenolate mofetil, 4(8%)-methotrexate, 37(71%)–HCQ, and 9(19%)–on biologic (rituximab, belimumab). Both groups were matched by age and gender. Patients receiving antirheumatic therapy (group 2) had longer disease duration (96 vs 18 months, p<0,00001), lower disease activity (SLEDAI-2K 4 vs 11 scores, p<0,001), higher SLICC/DI (1 vs 0 score, p<0,001); lower percentage of them had skin lesions (11 vs 57%, p<0,0001), arthritis (22 vs 52%, p<0,05) and hematological disorders (24 vs 74%, p<0,0001) than “untreated” patients from the 1st group.Results:Valve insufficiency with varying degree of clinically insignificant regurgitation and pericarditis were the commonest pathology found in “untreated” and “treated” SLE patients based on TTE data. No differences in rates of valve insufficiency (95% and 83%), pericarditis (43% and 47%) (both exudative and adhesive), endocarditis (26% and 33%), median left ventricular (LV) ejection fraction (64[59-68]% and 64[61-69]%), LV end-systolic dimension (30[27-32]mm and 29[25-31]mm), LV end-diastolic dimension (48[45-50]mm and 45[42-49]mm), pulmonary artery systolic pressure (25[22-31]mm Hg and 23[22-30]mm Hg), LV diastolic disfunction (26% and 21%) and LV systolic dysfunction (9% and 6%), LV myocardial hypertrophy (14% and 21%) and left atrium dilatation (9% and 21%) were found between the “untreated” SLE patients and patients receiving antirheumatic therapy (p>0,05 for all cases). Higher rates of mitral and tricuspid valves prolapse was seen more often in “treatment-naїv” SLE patients: 16(47%) vs 10(21%), p<0,01.Conclusion:Valvular dysfunction (insufficiency with clinically insignificant regurgitation), pericarditis, endocarditis and LVDD were the most common cardiac TTE abnormalities in SLE patients. Antirheumatic therapy seems not to worsen structural and functional cardiac abnormalities based on TTE findings in SLE patients. Only mitral and tricuspid valves prolapse was seen more often in “treatment-naїv” SLE patients.Disclosure of Interests:None declared

Combination of Methotrexate and Leflunomide Is Safe and Has Good Drug Retention Among Patients With Psoriatic Arthritis

Psoriatic arthritis (PsA) is a potentially progressive immune-mediated musculoskeletal disease with the involvement of synovium, enthesis, and axial structures (especially the cervical spine and sacroiliac joints), along with the involvement of skin and nails. Even a short delay in the diagnosis and commencement of antirheumatic therapy can cause long-term damage and disabilities.1

The effect of drug treatment on functional outcomes of hip and knee joint replacement in patients with rheumatoid arthritis

Aim – to determine the effect of drug antirheumatic therapy on the functional outcomes of hip and knee arthroplasty in patients with rheumatoid arthritis. Materials and methods. The results of 160 operations of total hip arthroplasty and 148 operations of total arthroplasty of knee joints in patients with rheumatoid joint lesions were analyzed using mathematical methods of statistical processing. Patients were divided into 4 groups: Group I – without anti-inflammatory therapy, Group II – received hormone therapy, Group III – basic therapy and Group IV – received both the basic and hormonal therapy at the time of surgery. Results. The obtained results indicated a moderate correlation between therapy and the joint range of motion of the lower extremities using basic therapy and combined nonsteroidal, hormonal and basic therapy, and the range of motion differed significantly in combination therapy from hormonal alone. The highest scores of the J. Joseph, E. E. Kaufman rating scale were observed in combination therapy with NSAIDs, hormonal and basic therapy; the lower scores – in hormonal and NSAIDs combination; and the lowest ones – in the combination of basic therapy with NSAIDs. The greatest increase in the knee joint range of motion was observed in the patients who received hormonal drugs or basic therapy compared to the patients who did not take any one or received both of these medicines in combination. Almost the same effect of antirheumatic therapy on the results of both hip and knee arthroplasty was determined with an upward trend in percentage of good and excellent results in males regardless of the lesion location and the most optimal ratio between satisfactory-unsatisfactory and good-excellent results in the patients under 40 years of age. Conclusions. The studies conducted allow to consider the combined drug therapy as a factor of weak and moderate influence on the functional outcomes of hip and knee arthroplasty in the late stages of rheumatoid arthritis and suggest that antirheumatic drug therapy should not be discontinued in the perioperative period.

COVID-19 vaccination and antirheumatic therapy

The coronavirus disease 2019 (COVID-19) vaccination will be the largest vaccination programme in the history of the NHS. Patients on immunosuppressive therapy will be among the earliest to be vaccinated. Some evidence indicates immunosuppressive therapy inhibits humoral response to the influenza, pneumococcal and hepatitis B vaccines. The degree to which this will translate to impaired COVID-19 vaccine responses is unclear. Other evidence suggests withholding MTX for 2 weeks post-vaccination may improve responses. Rituximab has been shown to impair humoral responses for 6 months or longer post-administration. Decisions on withholding or interrupting immunosuppressive therapy around COVID-19 vaccination will need to be made prior to the availability of data on specific COVID-19 vaccine response in these patients. With this in mind, this article outlines the existing data on the effect of antirheumatic therapy on vaccine responses in patients with inflammatory arthritis and formulates a possible pragmatic management strategy for COVID-19 vaccination.