A. Fanouriakis

Recent progress in the treatment of lupus nephritis

The treatment of lupus nephritis has seen significant advances during the past decade mainly due to the publication of well-designed randomized clinical trials (RCTs). The choice of treatment is guided by the histopathologic classification but is also influenced by demographic, clinical, and laboratory characteristics that allow for the identification of patients at risk for more aggressive disease. For the induction arm, low-dose cyclophosphamide regimens and mycophenolate mofetil have been validated as alternatives to the established National Institutes of Health regimen of high-dose cyclophosphamide; for the maintenance phase, azathioprine and mycophenolate compete for treatment of first choice. Rituximab is efficacious in real-life clinical practice but ineffective in clinical trials. The role of recently approved belimumab in lupus nephritis eagerly awaits further documentation. Aggressive management of comorbid conditions, such as hypertension and dyslipidemia, is of utmost importance. Here, we review the latest advances in lupus nephritis therapy with a focus on recent RCTs as well as new biologic agents under development. Furthermore, we propose a therapeutic algorithm in an effort to facilitate clinical decision-making in this gradually changing landscape. Upcoming European and American recommendations should provide further clarification.

Validity of the Italian algorithm for the attribution of neuropsychiatric events in systemic lupus erythematosus: a retrospective multicentre international diagnostic cohort study

Objective To validate the Italian algorithm of attribution of neuropsychiatric (NP) events to systemic lupus erythematosus (SLE) in an external international cohort of patients with SLE. Methods A retrospective cohort diagnostic accuracy design was followed. SLE patients attending three tertiary care lupus clinics, with one or more NP events, were included. The attribution algorithm, applied to the NP manifestations, considers four weighted items for each NP event: (1) time of onset of the event; (2) type of NP event (major vs minor), (3) concurrent non-SLE factors; (4) favouring factors. To maintain blinding, two independent teams of assessors from each centre evaluated all NP events: the first provided an attribution diagnosis on the basis of their own clinical judgement, assumed as the ‘gold standard’; the second applied the algorithm, which provides a probability score ranging from 0 to 10. The performance of the algorithm was evaluated by calculating the area under curve (AUC) of thereceiver operating characteristic curve. Results The study included 243 patients with SLE with at least one NP manifestation, for a total of 336 events. 285 (84.8%) NP events involved the central nervous system and 51 (15.2%) the peripheral nervous system. The attribution score for the first NP event showed good accuracy with an AUC of 0.893 (95% CI 0.849 to 0.937) using dichotomous outcomes for NPSLE (related vs uncertain/unrelated). The best single cut-off point to optimise classification of a first NPSLE-related event was≥7 (sensitivity 87.9%, specificity 82.6%). Satisfactory accuracy was observed also for subsequent NP events. Conclusions Validation exercise on an independent international cohort showed that the Italian attribution algorithm is a valid and reliable tool for the identification of NP events attributed to SLE.

Balancing efficacy and toxicity of novel therapies in systemic lupus erythematosus.

Therapy of systemic lupus erythematosus has been facing the paradox of an overwhelming rate of trials testing novel potential therapeutic agents and the lack of US FDA approval of a single new drug for over five decades. Heterogeneity in disease phenotype, concomitant immunosuppressive medication and a lack of unequivocal hard end points for clinical trials have proven to be significant obstacles in establishing efficacy of candidate therapies. Nevertheless, combination regimens with already existing agents have shown efficacy with acceptable safety profiles, mainly in cases of refractory to conventional treatment disease. At the same time, positive results from trials with belimumab, an antibody that targets B cells, opened the way for approval of this agent for the treatment of lupus and lends hope for a new era in systemic lupus erythematosus therapeutics. Here, we review the latest advances in systemic lupus erythematosus therapy, focusing on the balance between efficacy and safety for combination therapeutic regimens and biologics under development.

THU0367 Familial Mediterranean Fever (FMF): A Single Center Clinical-Genetic Study

Background FMF is the prototype of autoinflammatory disorder characterized by recurrent self-limited inflammatory episodes.1FMF is an autosomal recessive disease that is prevalent among eastern Mediterranean populations. The responsible gene (MEFV) encodes for the pyrin protein (or marenostrin)2,3 and the most serious complication of the disease is amyloidosis Objectives To report on the clinical manifestations and genotypic variation in a cohort of FMF patients followed at the University Hospital of Crete. Methods During the period 2005-2013, 160 patients were evaluated for possible FMF. The diagnosis was established according to clinical judgment and genetic analysis for the 12 most frequent MEFV mutations (based on the “FMF Strip Assay”). We reviewed the clinical, laboratory and genetic characteristics in patients who are evaluated in the clinic on a regular basis. Results 106 patients (50% women) were diagnosed with FMF with an average age 23.5 years (range 1-60) at the time of first attack. Combined MEFV heterozygosity and homozygosity was found in 31.1% of the patients, while 19.9% of patients carried no mutation. MEFV M694V was the most frequent (49.5%) mutation. The most frequent presenting manifestations were abdominal pain and fever (Table 1). 78% of patients are receiving colchicine 1 mg/day, while 13% require >1 mg/day to prevent attacks. Only one patient receives IL1-blockade (anakinra) due to colchicine failure. No patients discontinued colchicine due to side effect. Amyloidosis developed in 2 patients. There were no differences in clinical manifestation or response to treatment among patients with a single mutation, two mutations, or no MEFV mutation at the time of diagnosis. Table 1 Clinical manifestations Patients (N=107) Fever 83 (78%) Abdominal pain 95 (89,6%) Pleural pain/ pleuritis 31( 29%) Pericarditis 5 (4,6%) Arthritis 17 (16%) Rash 4 (3,7%) Abdominal surgery/Laparotomy 29 (27%) /5 (4,7%) Crisis duration 2.92 days (1–7) Crisis frequency 14/year (3–52) Conclusions In a cohort of FMF patients in the Mediterranean island of Crete, the most common MEFV mutation was M694V and all but two patients had excellent prognosis on colchicine therapy. Genotype did not correlate with clinical manifestations or response to treatment. References Sohar E, Gafni J, Pras M, Heller H (1967) Familial Mediterranean fever. A survey of 470 cases and review of the literature.Am J Med 43:227–2532 French FMF Consortium. A candidate gene for familial Mediterranean fever. Nat Genet. 997;17:25-31. International FMF Consortium. Ancient missense mutations in a new member of the RoRet gene family are likely to cause familial Mediterranean fever. Cell. 1997;90:797-807. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.3363

SAT0204 Abatacept survival in rheumatoid arthritis patients at 2 years is 59%; its use as a 2nd line biologic agent and lower baseline haq predict better survival in clinical practice: a prospective, observational single center study

Background Long-term prospective observational studies are complementary to controlled clinical trials to explore effectiveness and safety of biological therapies in clinical practice. Objectives To study abatacept survival, reasons of discontinuation and clinical responses in everyday clinical practice of patients with rheumatoid arthritis (RA). Methods Prospective, observational single center study at the Rheumatology Clinic, University Hospital of Heraklion, Crete. At baseline, patient demographics, co-morbidities and disease characteristics are being recorded, while during follow-up, discontinuations, disease activity and adverse events are collected. For this analysis, all patients who received Abatacept intravenously from 6/2007 till 6/2016 were included. Kaplan-Meier curves and Cox regression analysis were used to determine drug survival and predictors thereof. Linear regression was used to compare DAS difference at 12 months between different lines of bDMARD therapy. Results A total of 224 patients (women: 87%, seropositive: 34%) were included. Median (IQR) age was 63 (56–70) years, disease duration 7.4 (4–13.4) years and baseline DAS28 5.9 (5.2–6.5). Abatacept was the 1st bDMARD in 59 (26%), 2nd in 71 (32%) and ≥3rd in 94 (42%) patients. During follow-up [total: 508 patient-years, median (IQR): 1.7 (0.7–3.3) years], 54% patients discontinued therapy (87% for treatment failure, 10% for adverse events). Two-year treatment persistence was 59%. In multivariable regression analysis, predictors of longer Abatacept survival were lower baseline HAQ [HR (95% CI) for unit increase =2.29 (1.5–3.48), p<0.001], longer disease duration [HR (95% CI) for ≥8 vs.<8 years=0.51 (0.30–0.88), p=0.016], Abatacept as 2nd vs 1st or ≥3rd bDMARD [HR =0.52 (0.30–0.91), p=0.022] and a more recent year of therapy start [HR=0.39 (0.16–0.95), p=0.022]. DAS28<3.2 and remission at 6 (12) months were achieved by 12% (18%) and 5% (7%) of patients respectively. DAS28 difference at 12 months was greater in patients who received Abatacept as the ≤2nd than those on ≥3rd bDMARD (p=0.009). A total of 312 adverse events were registered, of which 65 were serious (SAE). Incidence of total (serious) adverse events was 61 (13) /100 patients/year. SAE included 5 cases of cancer, 10 cardiovascular events and 24 infections, mainly of the respiratory tract. Conclusions In the present study, Abatacept survival at 2 years was 59%. The majority of patients discontinued therapy due to inadequate response. Use as a 2nd line biologic agent and lower baseline HAQ predicted better survival. Improvement in DAS was higher when Abatacept was used as the ≤2nd bDMARD. Rates of remission or low disease activity in clinical practice are rather low, while the safety profile was excellent. Disclosure of Interest None declared

SAT0054 Favorable Long-Term Outcome of Early Inflammatory Arthritis in Clinical Practice: High Baseline Haq and Das28 at 3 Months Predict Use of Biologics

Background The course and natural history of early inflammatory arthritis (EA) varies widely and partly depends on the level of disease control in the early stages. Dedicated EA clinics follow a systematic targeted approach to improve long-term outcome of patients. Objectives To assess the long-term outcome of EA following care in a dedicated early arthritis outpatient clinic. Methods The “Early Arthritis (EA) Cohort” of the Department of Rheumatology of the University Hospital of Crete is a prospective cohort, which follows patients with inflammatory arthritis [RA, spondylarthritis or undifferentiated (UA)] of less than 6 months duration. Patients are followed quarterly for 2 years with systematic documentation of disease activity and function (measured by the DAS28 and HAQ, respectively), as well as for changes in therapy based on physician judgment. For the purpose of this study, we assessed long-term outcome (disease activity and function at 2 years) and examined prognostic factors for subsequent initiation of biologic agent. Results Out of 559 patients referred to the EA Clinic, a total of 317 had a final diagnosis of RA or UA and were included in the present analysis [83.0% women, mean (SD) age at disease diagnosis 53.7 (15.1) years, 28.5% positive for RF or/and ACPA, mean (SD) number of tender and swollen joints at baseline 6.9 (6.0) and 5.5 (5.5), respectively. Mean (SD) DAS 28 at baseline was 4.59 (1.38) and mean HAQ was 0.59 (0.51), with 33.9% of patients having high disease activity (DAS28>5.1) and 18.3% reporting a HAQ≥1. At 2 years of follow-up, mean (SD) DAS28 and HAQ were 3.63 (1.3) and 0.49 (0.48), respectively (p<0.001 compared to baseline values for both). Nevertheless, 38.3% of patients still had moderate and 13.8% high disease activity at 2 years, while 19.3% reported a HAQ>0.75. During the course of follow-up, 34 patients received a biologic agent due to persistent high disease activity. In multivariate regression analysis, factors associated with initiation of biologic were HAQ at baseline [adjusted RR (95% CI) 4.91 (3.54–6.81)] and DAS28 at 3 months [adjusted RR (95% CI) 1.49 (1.15–1.93)]. Conclusions Routine care with regular, objective documentation of disease activity and function is associated with satisfactory long-term outcomes in early inflammatory arthritis. Baseline impaired function and persistent disease activity at 3 months predict need for biologic treatment during follow-up. Disclosure of Interest None declared

FRI0316 Assessing Attribution of Neuropsychiatric Events in Systemic Lupus Erythematosus. Performance of A New Algorithm in An International Multicenter Cohort

Background In a recent study of a large cohort of systemic lupus erythematosus (SLE) patients, we evaluated a new algorithm to determine the attribution of neuropsychiatric (NP) events to SLE or other causes [1]. Objectives In the present study, we tested the performance of the algorithm in a new international multicenter cohort of patients, all of whom had one or more NP events as per the 1999 ACR case definitions. Methods A similar methodology to that used in the first study, was adopted. A dedicated electronic chart was created, including the core set of items for classification. Four factors were considered for each NP event (i) the time of onset of the NP event; (ii) the presence of concurrent or confounding non-SLE factors (i.e. “associations” suggested in the glossary for the 1999 ACR case definition); (iii) the type of NP event (major vs minor or common according to what has been proposed by Ainiala et al. [2]; (iv) the presence of “favouring factors” (i.e. supporting attribution). Patients from each center satisfied classification criteria for SLE and had one or more NP events. To maintain blinding, thus avoiding circular thinking, all events were evaluated by two independent assessors from each center, each assigned different tasks: the first assessor provided an attribution diagnosis (related/uncertain/not related to SLE) on the basis of their clinical judgement utilizing all of the information available in the patient record; the second assessor applied the attribution algorithm using the same available information and provided an attribution score. The performance of the attribution score was compared to the attribution determined by clinical judgement, which was taken as the “gold standard”. Receiver Operating Curve (ROC) analysis was used to determine the area under the curve (AUC) and the calculation of sensitivity, specificity, positive and negative predictive values [PPV and NPV (CI 95%)] using dichotomous outcomes (related vs uncertain/not related to SLE). Results There were 243 SLE patients (23 M, 220 F; mean (SD) age 47 (12.7) years with 336 NP events. Using a pre-defined attribution score cut-off ≥7 (derived by our previous national validation study of NP events related vs uncertain/not related to SLE) the AUC was 0.89 for NP events attributed to SLE with sensitivity of 88.5% (95% CI 77.7, 87.5), specificity of 74.6% (95% CI 67.9, 80.53), a PPV of 81.8% (95% CI 75.8, 86.8) and a NPV of 83.4% (95% CI 75.9, 89.3). Conclusions The attribution algorithm for evaluating NP events in SLE patients compared favourably to the judgement of experienced clinicians for the majority of NP events. It is a valid tool and provides a standardized approach to determining the attribution of NP events in future studies of NPSLE. References A. Bortoluzzi et al. Rheumatology 2015;54:891–898. H. Ainiala et al. Neurology 2001;57:496–500. Disclosure of Interest None declared

A5.26 Regulation of Expression and Function of Negative Immunomodulatory Receptors in B-Cells: Implications for the Pathogenesis of Systemic Lupus Erythematosus

Background and Objectives Fine tuning of B-cell activation and differentiation depends on convergent signals from the B-cell receptor (BCR), costimulatory/coinhibitory membrane receptors, and Toll-like receptors. We sought to examine the expression and function of the coinhibitory receptors programmed death-1 (PD-1), PD-1 ligand-1 (PD-L1), B and T lymphocyte attenuator (BTLA) in B-cells from healthy donors, and from patients with systemic lupus erythematosus (SLE), the prototype of systemic autoimmune disease characterised by activated B-cells and production of high-titer autoantibodies by long-lived plasma cells. Materials and Methods Peripheral blood CD19+ B cells were purified from healthy donors (n = 11) and active SLE patients (n = 15; SLE disease activity index 8.3 ± 2.7 [mean ± SEM]). PD-1, PD-L1, and BTLA were examined by flow cytometry in naïve (CD19+CD27–), memory/transitional (CD19+CD27+), and plasma B-cells (CD19+CD27hi) at baseline and following stimulation. Activation, differentiation, and proliferation (CFSE dilution) of B-cells were examined in the presence or absence of the BTLA ligand, HVEM. Western blot was used to assess the phosphorylation of intracellular kinases. Results In healthy donors, the coinhibitory receptors PD-1 and PD-L1 were significantly upregulated on circulating plasma-cells compared to transitional/memory and naïve B-cells (PD-1: 36 ± 7%, 14 ± 3%, 2.0 ± 0.5%; PD-L1: 94 ± 2%, 83 ± 5%, 62 ± 8%, respectively, p < 0.001). BTLA was expressed by 93–100% of B-cells, and mean fluorescence intensity was significantly higher in plasma-cells (334 ± 146 versus 127 ± 12 in naïve B-cells, p = 0.048). BCR activation enhanced the expression all three receptors in normal B-cells; addition of CpG-ODN (TLR-9 ligand) further induced PD-1 and PD-L1-but not BTLA–expression, whereas addition of the cytokines IL-4, IL-10, or IL-21 reduced PD-1 and BTLA levels. In vitro crosslinking of BTLA resulted in reduction of BCR-induced phosphorylation of ERK, CD80/CD86 and BAFF-receptor expression, as well as in inhibition of cell proliferation (divided cells: 5.3 ± 0.4% versus 17.7 ± 0.1% in anti-IgM-stimulated cells). In comparative analysis, SLE patients exhibited significantly higher PD-1 expression on plasma-cells compared to healthy donors (65 ± 5% versus 36 ± 7%, p = 0.002), whereas there was no difference in PD-L1 or BTLA. Preliminary studies suggest distinct roles for PD-1 and BTLA in regulation of activation and maturation of B-cells in healthy controls and in the context of lupus. Conclusions The coinhibitory receptors PD-1, PD-L1 and BTLA demonstrate differential expression among B-cell subsets and they are induced upon stimulation with important implications for the regulation of B-cell activation, proliferation and differentiation. Aberrancies in the expression and function of coinhibitory receptors in SLE plasma B-cells could contribute to enhanced autoantibody-forming capacity and disease pathogenesis.

AB0388 Coexistence of systemic lupus erythematosus and multiple sclerosis. prevalence and natural history

Background Although segregation of systemic lupus erythematosus (SLE) and multiple sclerosis (MS) has been reported within families with multiple members affected with autoimmune diseases, coexistence of the two disorders in the same individual has only rarely been described. Objectives To describe the clinical characteristics of patients fulfilling the criteria for both SLE and MS. Methods We reviewed the medical records, laboratory and neuroimaging findings in six patients diagnosed with both SLE (ACR 1987 criteria) and MS (2010 revised McDonald criteria). Cases were identified from existing cohorts of patients with SLE (n = 728) and MS (n = 819), followed in the Departments of Rheumatology and Neurology, University of Crete. Results All six patients were women, with an average age of SLE diagnosis at 44 years (Table), which is relatively higher from the usual age of disease onset. Antiphospholipid antibodies (aPLs) were present in two patients (33%), but none fulfilled criteria for antiphospholipid syndrome. In five patients, the diagnosis of SLE preceded the development of MS, in four of them with a time lag of ≤ 5 years (median 4 years, range from 2 to 16 years). Only one patient (case #2) had a long-standing (>20 years) history of relapsing-remitting MS (RRMS) before developing SLE. Clinical presentation of MS included spinal symptoms in five patients. All patients had mild SLE with cutaneous, mucosal and musculoskeletal manifestations, and only case #3 had history of pericarditis. Accordingly, therapeutic decisions were mainly guided by the severity of the neurological syndrome (Table). During median follow-up of 4 years (range 1-9 years), three patients remained stable and the remaining experienced gradual deterioration in their neurological status. SLE remained quiescent in all patients with standard immunomodulatory MS therapy. Conclusions Although SLE and MS may have overlapping features, occurrence of patients fulfilling criteria for both diseases is rare, confirming microarray findings for distinct molecular signatures[1]. In our cohort, SLE and MS co-existence was not associated with a severe phenotype for both entities. Longitudinal, larger cohorts in other ethnic groups are needed to further verify these findings. References Feng X, Reder NP, Yanamandala M, Hill A, Franek BS, Niewold TB, et al. Type I interferon signature is high in lupus and neuromyelitis optica but low in multiple sclerosis. J Neurol Sci. 2012 Feb 15; 313(1-2):48-53. Disclosure of Interest None Declared

Defects within the Myeloid Derived Supressor Cells (MDSCS) Compartment may Facilitate Aberrant Immune Responses in Systemic Lupus Erythematosus (SLE)

Background and objectives There is a currently unmet need to define the mechanisms involved in the homeostatic control of the immune response in autoimmune diseases. MDSCs (characterised in mice as CD11b+Gr1+ and in humans as CD14-HLA-DRlowCD15+CD33+) represent a heterogeneous population of myeloid precursors of macrophages, dendritic cells and granulocytes with a distinct regulatory role in suppressing T-cell responses. We sought to delineate the role of these cells both in murine and human lupus. Materials and methods We used the lupus prone (NZB x NZW) F1 female mice [3 months old, pre-SLE (n=6) and 6-8 months old, SLE mice (n=6)]. C57BL/6 (B6) female mice [3 mo (n=2) or 6 mo (n=6)] were used as controls. B6 mice immunised with myelin peptide in adjuvant (Experimental Autoimmune Encephalomyelitis) were used as a disease control. Cells were isolated from the bone marrow and spleen of the indicated groups and were stained with fluorescent-conjugated antibodies. Cells were stained for the aforementioned markers and for 7AAD. Analysis was performed in humans as well, using samples from SLE patients (n=18), healthy controls (n=20) and multiple sclerosis (MS) patients (n=31) as disease control. The phenotype and enumeration of cell populations were performed by flow cytometry. Results Compared to healthy B6 mice, splenic MDSCs of pre-SLE F1 animals were decreased both in frequency and absolute numbers (*p=0.012), indicating a defect in the MDSC compartment in F1 lupus mice. MDSCs were significantly expanded in the spleen of F1 diseased animals compared to healthy F1 controls (*p=0.017) albeit at significantly lower levels compared to mice with EAE (***p<0.0001). In humans, subjects with active lupus (n=8) exhibited higher numbers of MDSCs in the peripheral blood compared to inactive patients (n=10) and healthy controls, but at lower levels compared to patients with active MS (n=14). Ongoing experiments using in vivo transfer of murine MDSCs address their potential to halt renal disease progression and the cells/molecules involved. Conclusions Together these data suggest defective MDSC accumulation and/or expansion in the periphery in lupus which may contribute to the immune deregulation observed in this disease. Identification of the cell subsets and the molecules involved may provide additional therapeutic targets for the restoration of immune tolerance in lupus.