C. Pitzalis

Interleukin-27 inhibits ectopic lymphoid-like structure development in early inflammatory arthritis

Decreased interleukin-27 signaling in humans and mice induces the formation of ectopic lymphoid-like structures (ELSs), which are associated with severe disease pathology and resistance to biological therapy in rheumatoid arthritis patients. Increased numbers of podoplanin-expressing Th17 cells in the absence of IL-27R signaling may be involved in driving ELS formation.

Synovial tissue research: a state-of-the-art review

The synovium is the major target tissue of inflammatory arthritides such as rheumatoid arthritis. The study of synovial tissue has advanced considerably throughout the past few decades from arthroplasty and blind needle biopsy to the use of arthroscopic and ultrasonographic technologies that enable easier visualization and improve the reliability of synovial biopsies. Rapid progress has been made in using synovial tissue to study disease pathogenesis, to stratify patients, to discover biomarkers and novel targets, and to validate therapies, and this progress has been facilitated by increasingly diverse and sophisticated analytical and technological approaches. In this Review, we describe these approaches, and summarize how their use in synovial tissue research has improved our understanding of rheumatoid arthritis and identified candidate biomarkers that could be used in disease diagnosis and stratification, as well as in predicting disease course and treatment response.

Ultrasound of metacarpophalangeal joints is a sensitive and reliable endpoint for drug therapies in rheumatoid arthritis: results of a randomized, two-center placebo-controlled study

IntroductionWe aimed to investigate the sensitivity and reliability of two-dimensional ultrasonographic endpoints at the metacarpophalageal joints (MCPJs) and their potential to provide an early and objective indication of a therapeutic response to treatment intervention in rheumatoid arthritis (RA).MethodsA randomized, double-blind, parallel-group, two-center, placebo-controlled trial investigated the effect on ultrasonographic measures of synovitis of repeat dose oral prednisone, 15mg or 7.5mg, each compared to placebo, in consecutive two-week studies; there were 18 subjects in a 1:1 ratio and 27 subjects in a 2:1 ratio, respectively. All subjects met the 1987 American College of Rheumatology criteria for the diagnosis of RA, were ≥18 years-old with RA disease duration ≥6 months, and had a Disease Activity Score 28 based on C-reactive protein (DAS28(CRP)) ≥3.2. Subjects underwent high-frequency (gray-scale) and power Doppler ultrasonography at Days 1 (baseline), 2, 8 and 15 in the dorsal transverse and longitudinal planes of all 10 MCPJs to obtain summated scores of quantitative and semi-quantitative measures of synovial thickness as well as vascularity. The primary endpoint was the summated score of power Doppler area measured quantitatively in all 10 MCPJs in the transverse plane at Day 15. Clinical efficacy was assessed at the same time points by DAS28(CRP).ResultsAll randomized subjects completed the trial. The comparison between daily 15 mg prednisone and placebo at Day 15 yielded a statistically significant treatment effect (effect size = 1.17, P = 0.013) in change from baseline in the primary endpoint, but borderline for prednisone 7.5 mg daily versus placebo (effect size = 0.61, P = 0.071). A significant treatment effect for DAS28(CRP) was only observed at Day 15 in the prednisone 15 mg group (effect size = 0.95, P = 0.032). However, significant treatment effects at all time points for a variety of ultrasound (US) endpoints were detected with both prednisone doses; the largest observed effect size = 2.33. Combining US endpoints with DAS28(CRP) improved the registration of significant treatment effects. The parallel scan inter-reader reliability of summated 10 MCPJ scores were good to excellent (ICC values >0.61) for the majority of US measures.ConclusionsUltrasonography of MCPJs is an early, reliable indicator of therapeutic response in RA with potential to reduce patient numbers and length of trials designed to give preliminary indications of efficacy.Trial RegistrationClinicaltrials.gov identifier: NCT00746512

Eligibility for clinical trials in primary Sjogren's syndrome: lessons from the UK Primary Sjogren's Syndrome Registry.

OBJECTIVE To identify numbers of participants in the UK Primary Sjögrens Syndrome Registry (UKPSSR) who would fulfil eligibility criteria for previous/current or potential clinical trials in primary SS (pSS) in order to optimize recruitment. METHODS We did a retrospective analysis of UKPSSR cohort data of 688 participants who had pSS with evaluable data. RESULTS In relation to previous/current trials, 75.2% fulfilled eligibility for the Belimumab in Subjects with Primary Sjögrens Syndrome study (Belimumab), 41.4% fulfilled eligibility for the Trial of Remicade in primary Sjögrens syndrome study (Infliximab), 35.4% for the Efficacy of Tocilizumab in Primary Sjögrens Syndrome study (Tocilizumab), 31.6% for the Tolerance and Efficacy of Rituximab in Sjögrens Disease study (Rituximab), 26.9% for the Trial of anti-B-cell therapy in pSS study (Rituximab) and 26.6% for the Efficacy and Safety of Abatacept in Patients With Primary Sjögrens Syndrome study (Abatacept). If recent measures of outcome, such as the EULAR Sjögrens Syndrome Patient Reported Index (ESSPRI) score ⩾5 (measure of patient symptoms) and the EULAR Sjögrens Syndrome Disease Activity Index (ESSDAI) score ⩾5 (measure of systemic disease activity) are incorporated into a study design, with requirements for an unstimulated salivary flow >0 and anti-Ro positivity, then the pool of eligible participants is reduced to 14.3%. CONCLUSION The UKPSSR identified a number of options for trial design, including selection on ESSDAI ⩾5, ESSPRI ⩾5 and serological and other parameters.

SAT0242 How good are the eular sjögren’s syndrome disease activity index (ESSDAI), and EULAR sjögren’s syndrome patients reported index (ESSPRI) in predicting health status in primary sjögren’s syndrome?

Background Over the past 2 years, the EULAR Sjogren’s syndrome study group have developed 2 new instruments, ESSDAI and ESSPRI to measure systemic disease activity and overall symptom burden. The ESSPRI also generates an EULAR sicca score (ESS) which measures the overall symptom of dryness. These instruments are designed to be used as standardised outcome measures for clinical studies and trials. Therefore it is useful to investigate how well these instruments predict the health status of patients with primary Sjogren’s syndrome (PSS). EQ-5D is a generic instrument that measure health outcome, the value sets can be converted to Time Trade Off (TTO) values representing the time a patient would be willing to give up to be freed from a reduced health state. In this study, we examined the relationship between ESSDAI and ESSPRI and the TTO values derived from EQ-5D. Objectives To evaluate the relationship between the two new instruments for the assessment of PSS (ESSDAI and ESSPRI) and health status of PSS patients. Methods Data including ESSDAI, ESSPRI and EQ-5D were prospectively collected from 633 PSS patients who have participated in the UK PSS registry (UKPSSR) using a standardised pro forma as previously described (1). TTO values were derived from the UK reference data provided by EuroQoL (the developer of the EQ-5D instrument) which has been transformed so that the values range from -1 to 1, with 1 being the number of years in perfect health state, 0 being dead and negative values representing health states worse than being dead. The relationships between the derived TTO values based on the health state of the patients and ESSDAI, ESSPRI as well as ESS were determined. Results The mean±SD TTO value of the PSS cohort was 0.624±0.301, with a range of -0.239 to 1. There were statistically significant correlations between TTO and ESSDAI, ESSPRI and ESS; TTO values decreased with increased ESSDAI, ESSPRI and ESS values (p<0.001 for all three). The strength of correlation was strongest with ESSPRI (R=-0.64), followed by ESS (R=-0.29) and ESSDAI (R=-0.15). Conclusions The recently developed EULAR PSS outcome assessment tools, in particular the ESSPRI, are useful predictors of the health status of PSS patients. Other UKPSSR collaborators: Moots R, Chadravarty K, Gendi N, Hamburger J, Richards A, Rauz S, Mulherin D, Kitas GD, Lloyd M, Lawson C, Clunie G, Knight S, Symmons D, Carr A, Carrozzo M, Figuereido F, Macleod I, Tarn JR, Foggo H, Edgar S,Young-Min S, Field A, Kaye S, Mewar D, Akil M, Dasgupta B, Fedele S, Porter S, Li C, Hall F. References Ng WF et al, Rheumatology, 2011;50:32-9. Disclosure of Interest None Declared

THU0087 Synovial Ectopic Lymphoid-like Structures are Associated with Diagnosis of Rheumatoid Arthritis, Disease Activity and Antibody Status in Early Arthritis Patients

Background The presence of ectopic lymphoid-like structures (ELS) within the synovial tissue of a cohort of patients with inflammatory arthritis is well recognised. There is also data supporting the concept that these structures are immunologically competent and can support chronic inflammation within the joint. There is limited data however examining whether the presence of ELS associates with specific clinical phenotypes in early arthritis. Objectives The aim of this study was therefore to investigate whether synovial ELS associated with specific clinical phenotypes in an early arthritis cohort. Methods A cohort of DMARD-naïve early arthritis (<12 months duration, at least 1 swollen joint) patients recruited at Barts and The London Hospital, as part of the MRC-funded Pathobiology of Early Arthritis Cohort (PEAC) http://www.peac-mrc.mds.qmul.ac.uk/ were included in the analysis. The study was approved by the ethics committee (REC). Baseline disease characteristics assessed included erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, rheumatoid factor (RF), anti-cyclic-citrullinated peptide antibodies (anti-CCP) and 28 joint-disease activity score (DAS28). All patients underwent ultrasound-guided synovial biopsy of an affected joint at baseline. Sections of paraffin embedded RA synovial tissue were stained with standard Haematoxylin and Eosin (H&E) and graded as either a diffuse or aggregate synovitis. In addition sequentially cut paraffin sections underwent immunohistochemical staining for B-cells(CD20), T cells (CD3) and macrophages(CD68) and were semi-quantitatively scored (0-4) for each marker. Results 84 sequentially recruited patients with both synovial tissue and a complete clinical data set were included within the analysis (61% female, mean age 50). 64% (n=57) of patients were classified as diffuse and 36% (n=27) as aggregate. The presence of synovial lymphocytic aggregates was significantly associated with higher synovial infiltration of T cells, B cells, plasma cells and both lining and sublining macrophages (p<0.001). Moreover, the presence of synovial aggregates was significantly associated with baseline RA diagnosis (1987 ACR criteria), positive ESR/CRP and seropositivity for RF and anti-CCP antibodies. Interestingly, there was also a significant correlation between a higher synovial infiltration of B cells and plasma cells and positivity for anti-CCP antibodies (p=0.002 and p<0.001) and RF (p<0.001 and p<0.001) in the serum. Conclusions The significant association of synovial ELS with the diagnosis of RA and sero-positivity for RF and anti-CCP antibodies in early arthritis stronlgly supports the concept that these structures are functional and involved in disease pathogenesis. In addition these observations also suggest that baseline synovial pathotype may have a role as a prognostic biomarker in early arthritis. Disclosure of Interest None Declared

FRI0448 Evaluating health status of 620 patients with primary sjÖgren’s syndrome using EQ-5D

Background EQ-5D is a standardised tool for measurement of health status and is an increasingly popular health-related quality of life instrument but has not been applied to patients with primary Sjögren’s syndrome (PSS). EQ-5D provides a simple descriptive profile, a single index value for health status and a visual analogue score (VAS). The key advantages of EQ-5D are that the instrument is preference-based, easy to complete and the value sets can be easily converted to Quality Adjusted Life Years (QALY) to aid cost-utility analysis. Objectives To evaluate the health status of a large cohort of patients with primary Sjogren’s syndrome in the UK using EQ-5D. Methods We evaluated the health status of 620 clinically well characterised PSS patients from the UK PSS registry (UKPSSR) who fulfil the American European Consensus Group classification criteria 2002. All data were collected prospectively using a standardised pro forma as previously described (1). Data were compared to the UK normative data provided by the EuroQoL. In addition, the relationship between the health status of PSS patients and various clinical and patient reported outcome measures of PSS were examined. Results The proportion of PSS patients reporting any problem in mobility, self-care, usual activities, pain/discomfort & anxiety/depression were 42.4, 16.9, 56.7, 81.1 & 49.6 (%) respectively compared to 5.4, 1.6, 7.9, 30.2 & 15.7 (%) in the general UK population. The mean±SD VAS score was 59.9±21.2, compared to 81.3±16.8 for the general UK population. Univariate correlation analysis showed that EQ-5D VAS correlated with many clinical features of PSS but most strongly with fatigue, depression and pain with R values >0.5. Among the laboratory measures, only IgG levels, paraproteins and C3 correlated with EQ-5D VAS. Hierarchical cluster analysis showed that depression and fatigue are the most important determinants of variations in health status in this PSS cohort. Conclusions To our knowledge, this is the first report on the health status of PSS patients using EQ-5D. PSS patients have significantly impaired health status compared to the UK general population. Depression and fatigue are the key determinants of health status in PSS. Our data adds to the growing body of evidence that effective management of fatigue is key to improving the health status of PSS patients. References Ng WF et al, Rheumatology, 2011;50:32-9. Other UKPSSR collaborators: Moots R, Chadravarty K, Gendi N, Hamburger J, Richards A, Rauz S, Mulherin D, Kitas GD, Lloyd M, Moore L, Lawson C, Clunie G, Knight S, Symmons D, Carr A, Carrozzo M, Figuereido F, Macleod I, Tarn J, Foggo H, Mann S, Young-Min S, Field A, Kaye S, Mewar D, Akil M, Dasgupta B, Fedele S, Porter S, Li C, Hall F. Disclosure of Interest None Declared

FRI0103 Synovial Specific Prodrug for the Next Generation of Anti-TNF Therapy in Rheumatoid Arthritis

Background Despite the obvious success of anti-TNFα agents in Rheumatoid Arthritis (RA) treatment, high number of non-responders and systemic adverse effects,1 including reactivation of latent infections, highlight the need of broader efficacy and improved safety profiles. Recently the importance of angiogenesis in the progression of arthritis has been unveiled.2 Angiogenesis can be exploited for tissue selective drug delivery approaches to drive in situ drug accumulation reducing systemic side effects. Objectives Develop a bispecific antibody prodrug with vascular specificity to deliver an anti-TNFα payload to the arthritic tissue, allowing anti-TNFα activation selectively in the arthritic synovium and avoiding systemic TNFα engagement. Methods The anti-ICAM1 variable region was cloned in fusion with the anti-TNFα antibody Adalimumab in a dual variable domain (DVD) bispecific format. Linker between the outer and inner variable domain was engineered to be short and bear an MMP1 cleavable site forming an activatable DVD (aDVD) antibody. Reactivity with RA human synovium was determined using immunohistochemistry on tissue sections. MMP1-mediated antibody activation was tested using RA synovial fluids and RA synovial fibroblasts. Activity and biological functionality of the anti-TNFα moiety was assessed in vitro using ELISA, Biacore and L-929 TNFα-cytotoxicity assays. Human TNF transgenic mouse model of arthritis (tg197) was used to assess in vivo therapeutic activity. Results The aDVD bispecific antibody was able to retain synovial microvascular targeting, conveyed by the anti-ICAM1 variable domain, in RA synovial tissue sections. The intact molecule however, showed a reduced capacity to bind TNFα with 500-fold affinity decrease caused by steric hindrance of the outer variable region. Digestion with physiologically relevant concentrations of MMP1 was sufficient to restore 100% anti-TNFα activity (EC50 53 pM) comparable to the parent Adalimumab antibody (49 pM). The un-processed aDVD antibody was significantly impaired in rescuing the L-929 cell line from TNFα-induced cytotoxicity. Digestion with MMP1 and activation of the anti-TNFα domain restored the anti-TNFα biological activity with an IC50 of 0.1 nM equal to Adalimumab IgG (IC50 0.1 nM). The antibody was also able to localise in the arthritic joint and reduce bone degradation in the tg197 mouse model in vivo. Conclusions Our results demonstrate the development of a synovium-specific pro-drug delivery system for RA. The impaired TNFα binding capacity of the intact molecule ensures a decreased systemic TNFα engagement. Presence of metalloproteinases in RA synovium3 would activate and deliver the anti-TNFα activity locally in the site of disease. This strategy may allow greater therapeutically-relevant doses to be delivered in the synovium, increasing pharmacological potency, potentially allowing reduction in the dosage and/or administration frequency with the ultimate goal of reducing systemic exposure, achieve better therapeutic index and decreasing healthcare costs.4 References Taylor, P.C. & Feldmann, M. Nat Rev Rheumatol 5, 578-82 (2009). Paleolog, E. International journal of experimental pathology 90, 249-310 (2009). Manicourt, D.H., et al. Arthritis Rheum 38, 1031-9 (1995). Ferrari, M. et al. Nat Rev Rheumatol (in press) Disclosure of Interest None declared

THU0008 A Negative High-Resolution Salivary Gland Ultrasound is Highly Predictive of Negative Labial Gland Biopsy in Patients with SICCA Symptoms

Background Sjögrens syndrome (SS) is a chronic autoimmune disease that affects salivary and lacrimal glands and results in xerostomia and xerophtalmia. Current criteria require the presence of either anti-Ro/La antibodies (ENA) or a positive focus score at labial salivary gland biopsy (LSGB) for SS classification [1]. Salivary gland biopsy is a highly specific marker for the diagnosis of SS but as an invasive procedure it is often indicated only in ENA- patients with sicca symptoms. Objectives Here we investigated the capacity of high-resolution salivary gland ultrasound (US) to predict the result of a LSGB biopsy in a consecutive cohort of patient with sicca. Methods Eighty-five consecutive patients attending the Combined Oral Medicine/Rheumatology SS Clinic at Barts and The London NHS Trust who underwent US and LSGB were recruited in the study. All patients displayed subjective and objective symptoms and signs of sicca. US imaging was scored as described by Salaffi et al. [2] while LSGB were scored following immunohistology, including CD3/CD20/CD138/CD21 markers [3]. US and LSGB were scored blindly with the radiologist and the pathologist unaware of the clinical data. Results Of the 85 patients recruited, 36 fulfilled SS criteria (15 LSGB+ENA+, 16 LSGB+ENA−, 5 LSGB−ENA+) while 49 were classified as sicca (LSGB−ENA−). Within the whole cohort, abnormal US findings were observed in 34 patients, of these 29 displayed a positive LSGB. Concordance between US and LSGB was 91.76% (Kappa=0.826). Irrespectively of diagnosis and ENA status, the positive predictive value of having a positive LSGB with abnormal US findings was 85.29% whilst a negative US gave a negative LSGB predictive value of 96.08%. Conclusions Our results demonstrate that high-resolution salivary gland US has a high concordance with LSGB. In particular, a negative US result is highly predictive of a negative labial gland biopsy in patients with sicca symptoms. These data suggests that, particularly in ENA− patients, the role of US is to guide whether or not LSGB is indicated, thus avoiding an invasive procedure in patients with an extremely low chance of a positive result. Thus, we propose that US should be considered in the SS diagnostic algorithm as a screening test before LSGB is performed. References Vitali C, Bombardieri S, Jonsson R, Moutsopoulos HM, Alexander EL, Carsons SE, et al. Classification criteria for Sjogrens syndrome: a revised version of the European criteria proposed by the American-European Consensus Group. Ann Rheum Dis. 2002 Salaffi F, Carotti M, Iagnocco A, Luccioli F, Ramonda R, Sabatini E, et al. Ultrasonography of salivary glands in primary Sjogrens syndrome: a comparison with contrast sialography and scintigraphy. Rheumatology (Oxford). 2008 Barone F, Bombardieri M, Rosado MM, Morgan PR, Challacombe SJ, De Vita S, et al. CXCL13, CCL21, and CXCL12 expression in salivary glands of patients with Sjogrens syndrome and MALT lymphoma: association with reactive and malignant areas of lymphoid organization. J Immunol. 2008 Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.3114

OP0040 Synovial cell infiltration in acpa-ve patients displays similar signatures to other seronegative inflammatory arthritis. results from the pathobiology of early arthritis cohort (PEAC)

Background There is increasing evidence to suggest that ACPA +ve and ACPA-ve RA are distinct diseases. Current data demonstrates overlap in classification criteria between ACPA-ve RA and other sero negative inflammatory arthritidies such as PsA. Associated with this is a variable prognosis and response to treatment for patients with ACPA-ve RA. Biomarkers capable of refining diagnosis and improving on current classification criteria early in the disease course for patients with ACPA-ve RA are thus urgently needed. Data examining the synovial pathophysiological relationship between PsA and ACPA ±RA is currently limited although has the potential to identify disease specific synovial cellular and molecular signatures. Objectives Therefore, the aim of this study is to examine in a cohort of therapy naïve, early inflammatory arthritis patients, whether ACPA-ve RA can be defined at disease initiation according to synovial pathobiological signatures. Methods A total of 186 consecutive DMARD naïve inflammatory arthritis patients (disease duration <1 year) recruited as part of the multicentre PEAC study at Barts Health NHS Trust were evaluated. All patients underwent a baseline synovial biopsy of a clinically active joint along with collection of inflammatory markers (CRP). Following H and E staining, sections underwent immumohistochemical staining and semi-quantitative scoring (0–4) to determine the degree of CD20 +Bcells, CD3 +T cells, CD68 +lining (l) and sublining (sl) macrophage and CD138 +plasma cell infiltration. Sections were categorised into three pathotypes: (i) Fibroid(F):(CD68 SL <2 and or CD3, CD20, CD138 <1), (ii) Myeloid(M):(CD68SL >2, CD20 <1 and or CD3 >1) and (iii) Lymphoid(L):(grade 2–3 CD20 +aggregates, CD20 >2). Results 90/186 patients were classified as ACPA+ve RA, 55/186 as ACPA-ve RA and 41/186 as PsA. 80% of synovial samples were collected from small joints (wrist, MCP, PIP). All 186 samples were suitable for analysis. Results confirmed that C-reactive protein (CRP) as inflammatory marker does not differentiate between subgroups (p 0.41). Significantly higher degree of immune cell infiltration was seen between ACPA+ve vs ACPA-ve and ACPA+ve vs PsA but not between ACPA-ve and PsA (figure 1). When grouping patient between clinical subgroups (ACPA+ve vs ACPA-ve vs PsA) and pathotypes (fibroid, myeloid and lymphoid) (table1) we demonstrated a significantly higher prevalence of a lymphoid pathotype in ACPA+ve RA vs ACPA-ve or PsA. RA acpa +N909ungraded RA acpa-N5512ungraded PsAN410ungraded P value fisher test P value acpa+vs acpa- P value acpa+vs PsA P value acpa- vs PsA F 15 (16%) 17 (31%) 15 (36%) 0.01* 0.03* 0.005* 0.41 M 25 (28%) 14 (25%) 11 (27%) L 41 (45%) 12 (22%) 10 (24%) Conclusions Our results suggest that the synovial cell infiltrate (B cells, T cells, macrophages and plasma cells) in ACPA-ve RA is significantly different from ACPA +ve patients. They also suggest shared pathophysiological mechanisms between PsA and ACPA-ve RA and support a role for future refinement of diagnosis of ACPA-ve RA according to synovial pathobiology. Disclosure of Interest None declared