H.-M. Lorenz

[Ocular involvement in spondyloarthropathies: HLA B27 associated uveitis].

ZusammenfassungDie häufigste extraartikuläre Manifestation der Spondyloarthritiden (SPA) ist die Augenbeteiligung. Sie tritt bei 30–50% der SPA-Patienten auf. Hierbei sind insbesondere die HLA-B27-positiven Patienten – am häufigsten die Subgruppe der Patienten mit ankylosierender Spondylitis – betroffen. Die Prävalenz einer Uveitis steigt mit der Dauer der Erkrankung. Typischerweise kommt es zu einer akut auftretenden einseitigen Uveitis anterior (Iridozyklitis), die in unkomplizierten Fällen gut auf Lokalsteroide anspricht. Bei rezidivierenden bzw. chronischen Verläufen kommen neben systemischen Steroiden auch die klassischen Basistherapeutika und in zunehmendem Maße auch die TNF-α-Hemmer zum Einsatz. Bei Letzteren wird den monoklonalen Antikörpern der Vorzug vor dem Rezeptorantagonisten gegeben. Als Minimalvariante bzw. erstes Symptom einer SPA kann eine akute anteriore Uveitis auftreten. Auch diese Patienten sollten vom Rheumatologen mitbeurteilt werden, da sich bei einem nicht unerheblichen Prozentsatz der Betroffenen eine bisher nicht diagnostizierte SPA findet, die in die weiteren therapeutischen Überlegungen mit einbezogen werden sollte.AbstractThe most frequent extraarticular manifestation in spondyloarthropathies (SpA) is eye involvement, which is found in 30%–50% of patients. HLA B27 positive patients in particular – mostly those in the subgroup with ankylosing spondylitis – are affected. Prevalence of uveitis increases with duration of disease. Typical eye involvement is sudden-onset unilateral anterior uveitis (iridocyclitis). Most cases respond well to topical corticosteroids. Frequently relapsing or chronic cases may require oral corticosteroids in addition to classical immunosuppressive drugs and, to an increasing extent, also TNF-α inhibitors. In the case of the latter, monoclonal antibodies are preferred over receptor antagonists. Acute anterior uveitis may occur as a minimal variation or initial symptom of SpA. These patients should also be seen by a rheumatologist since undiagnosed SpA may be present in a significant percentage and should be included in therapeutic considerations.The most frequent extraarticular manifestation in spondyloarthropathies (SpA) is eye involvement, which is found in 30%-50% of patients. HLA B27 positive patients in particular--mostly those in the subgroup with ankylosing spondylitis--are affected. Prevalence of uveitis increases with duration of disease. Typical eye involvement is sudden-onset unilateral anterior uveitis (iridocyclitis). Most cases respond well to topical corticosteroids. Frequently relapsing or chronic cases may require oral corticosteroids in addition to classical immunosuppressive drugs and, to an increasing extent, also TNF-alpha inhibitors. In the case of the latter, monoclonal antibodies are preferred over receptor antagonists. Acute anterior uveitis may occur as a minimal variation or initial symptom of SpA. These patients should also be seen by a rheumatologist since undiagnosed SpA may be present in a significant percentage and should be included in therapeutic considerations.

Neufassung der Strukturqualität der akut-stationären Rheumatologie

ZusammenfassungAuf der Basis der Projektgruppenarbeit zur Strukturqualität wurden in 2010 9 vom Verband rheumatologischer Akutkliniken e.V. (VRA) verabschiedete Richtlinien zur Strukturqualität akut-stationärer Rheumakliniken aufgeführt. Diese 9xa0Strukturkriterien lösen die erstmals 2002 publizierten Richtlinien ab. Hervorzuheben ist hierbei, dass diese Neuentwicklung mit Unterstützung der deutschen Rheuma-Liga erfolgt ist. Erstmals wird auch mit der Richtlinie Nr. 9 zu den strukturellen Voraussetzungen Stellung genommen, die rheumatologische Einrichtungen an Universitätskliniken vorhalten sollten.Die neuen Strukturkriterien finden zukünftig ihren Einsatz bei der Erlangung eines extern zu vergebenden Qualitätslabels für die VRA-Kliniken, wofür neben der Erfüllung der strukturellen Richtlinien die Teilnahme am Qualitätsprojekt „Kobra“ (Kontinuierliches Outcome-Benchmarking in der rheumatologischen Akutversorgung) gefordert wird.Mit diesem Weg hat der VRA wichtige Voraussetzungen für die Mitgliedskliniken geschaffen, um für den zukünftigen Qualitätswettbewerb der Krankenhäuser gerüstet zu sein. Die Vorhaltung einer hohen Behandlungsqualität für die chronisch erkrankten Rheumapatienten innerhalb einer akut-stationären Betreuung bei entsprechender Aufnahmeindikation wird hierdurch nachhaltig unterstützt.AbstractIn 2010 a total of 9 guidelines on structural quality were endorsed by the Association of Rheumatology Clinics in Germany (VRA). These 9 structural criteria replace the regulations published in 2002 and were elaborated with the support of the German Rheumatology League. With guideline number 9 even the structural requirements for university hospitals are defined for the first time.Along with taking part in the quality project “Kobra” (continuous outcome benchmarking in rheumatology inpatient treatment) compliance with the new structural criteria constitutes a prerequisite for acquiring a quality certificate, which is awarded by an external institution.By this means the VRA sets the stage for its members to be prepared for future challenges and quality competition among hospitals. Furthermore, the provision of a high quality treatment for chronically diseased patients in rheumatology clinics will be effectively supported.In 2010 a total of 9 guidelines on structural quality were endorsed by the Association of Rheumatology Clinics in Germany (VRA). These 9 structural criteria replace the regulations published in 2002 and were elaborated with the support of the German Rheumatology League. With guideline number 9 even the structural requirements for university hospitals are defined for the first time.Along with taking part in the quality project Kobra (continuous outcome benchmarking in rheumatology inpatient treatment) compliance with the new structural criteria constitutes a prerequisite for acquiring a quality certificate, which is awarded by an external institution.By this means the VRA sets the stage for its members to be prepared for future challenges and quality competition among hospitals. Furthermore, the provision of a high quality treatment for chronically diseased patients in rheumatology clinics will be effectively supported.

[Amendment of the structural quality for inpatient rheumatology. A forward-looking concept].

ZusammenfassungAuf der Basis der Projektgruppenarbeit zur Strukturqualität wurden in 2010 9 vom Verband rheumatologischer Akutkliniken e.V. (VRA) verabschiedete Richtlinien zur Strukturqualität akut-stationärer Rheumakliniken aufgeführt. Diese 9xa0Strukturkriterien lösen die erstmals 2002 publizierten Richtlinien ab. Hervorzuheben ist hierbei, dass diese Neuentwicklung mit Unterstützung der deutschen Rheuma-Liga erfolgt ist. Erstmals wird auch mit der Richtlinie Nr. 9 zu den strukturellen Voraussetzungen Stellung genommen, die rheumatologische Einrichtungen an Universitätskliniken vorhalten sollten.Die neuen Strukturkriterien finden zukünftig ihren Einsatz bei der Erlangung eines extern zu vergebenden Qualitätslabels für die VRA-Kliniken, wofür neben der Erfüllung der strukturellen Richtlinien die Teilnahme am Qualitätsprojekt „Kobra“ (Kontinuierliches Outcome-Benchmarking in der rheumatologischen Akutversorgung) gefordert wird.Mit diesem Weg hat der VRA wichtige Voraussetzungen für die Mitgliedskliniken geschaffen, um für den zukünftigen Qualitätswettbewerb der Krankenhäuser gerüstet zu sein. Die Vorhaltung einer hohen Behandlungsqualität für die chronisch erkrankten Rheumapatienten innerhalb einer akut-stationären Betreuung bei entsprechender Aufnahmeindikation wird hierdurch nachhaltig unterstützt.AbstractIn 2010 a total of 9 guidelines on structural quality were endorsed by the Association of Rheumatology Clinics in Germany (VRA). These 9 structural criteria replace the regulations published in 2002 and were elaborated with the support of the German Rheumatology League. With guideline number 9 even the structural requirements for university hospitals are defined for the first time.Along with taking part in the quality project “Kobra” (continuous outcome benchmarking in rheumatology inpatient treatment) compliance with the new structural criteria constitutes a prerequisite for acquiring a quality certificate, which is awarded by an external institution.By this means the VRA sets the stage for its members to be prepared for future challenges and quality competition among hospitals. Furthermore, the provision of a high quality treatment for chronically diseased patients in rheumatology clinics will be effectively supported.In 2010 a total of 9 guidelines on structural quality were endorsed by the Association of Rheumatology Clinics in Germany (VRA). These 9 structural criteria replace the regulations published in 2002 and were elaborated with the support of the German Rheumatology League. With guideline number 9 even the structural requirements for university hospitals are defined for the first time.Along with taking part in the quality project Kobra (continuous outcome benchmarking in rheumatology inpatient treatment) compliance with the new structural criteria constitutes a prerequisite for acquiring a quality certificate, which is awarded by an external institution.By this means the VRA sets the stage for its members to be prepared for future challenges and quality competition among hospitals. Furthermore, the provision of a high quality treatment for chronically diseased patients in rheumatology clinics will be effectively supported.

Augenbeteiligung bei Spondyloarthritiden

ZusammenfassungDie häufigste extraartikuläre Manifestation der Spondyloarthritiden (SPA) ist die Augenbeteiligung. Sie tritt bei 30–50% der SPA-Patienten auf. Hierbei sind insbesondere die HLA-B27-positiven Patienten – am häufigsten die Subgruppe der Patienten mit ankylosierender Spondylitis – betroffen. Die Prävalenz einer Uveitis steigt mit der Dauer der Erkrankung. Typischerweise kommt es zu einer akut auftretenden einseitigen Uveitis anterior (Iridozyklitis), die in unkomplizierten Fällen gut auf Lokalsteroide anspricht. Bei rezidivierenden bzw. chronischen Verläufen kommen neben systemischen Steroiden auch die klassischen Basistherapeutika und in zunehmendem Maße auch die TNF-α-Hemmer zum Einsatz. Bei Letzteren wird den monoklonalen Antikörpern der Vorzug vor dem Rezeptorantagonisten gegeben. Als Minimalvariante bzw. erstes Symptom einer SPA kann eine akute anteriore Uveitis auftreten. Auch diese Patienten sollten vom Rheumatologen mitbeurteilt werden, da sich bei einem nicht unerheblichen Prozentsatz der Betroffenen eine bisher nicht diagnostizierte SPA findet, die in die weiteren therapeutischen Überlegungen mit einbezogen werden sollte.AbstractThe most frequent extraarticular manifestation in spondyloarthropathies (SpA) is eye involvement, which is found in 30%–50% of patients. HLA B27 positive patients in particular – mostly those in the subgroup with ankylosing spondylitis – are affected. Prevalence of uveitis increases with duration of disease. Typical eye involvement is sudden-onset unilateral anterior uveitis (iridocyclitis). Most cases respond well to topical corticosteroids. Frequently relapsing or chronic cases may require oral corticosteroids in addition to classical immunosuppressive drugs and, to an increasing extent, also TNF-α inhibitors. In the case of the latter, monoclonal antibodies are preferred over receptor antagonists. Acute anterior uveitis may occur as a minimal variation or initial symptom of SpA. These patients should also be seen by a rheumatologist since undiagnosed SpA may be present in a significant percentage and should be included in therapeutic considerations.The most frequent extraarticular manifestation in spondyloarthropathies (SpA) is eye involvement, which is found in 30%-50% of patients. HLA B27 positive patients in particular--mostly those in the subgroup with ankylosing spondylitis--are affected. Prevalence of uveitis increases with duration of disease. Typical eye involvement is sudden-onset unilateral anterior uveitis (iridocyclitis). Most cases respond well to topical corticosteroids. Frequently relapsing or chronic cases may require oral corticosteroids in addition to classical immunosuppressive drugs and, to an increasing extent, also TNF-alpha inhibitors. In the case of the latter, monoclonal antibodies are preferred over receptor antagonists. Acute anterior uveitis may occur as a minimal variation or initial symptom of SpA. These patients should also be seen by a rheumatologist since undiagnosed SpA may be present in a significant percentage and should be included in therapeutic considerations.

Problems associated with treating ocular disease in underlying inflammatory rheumatic disease

ZusammenfassungAugenbefunde können wegweisend für rheumatologische Systemerkrankungen sein. Im Mittelpunkt dieser okulären Krankheitsbilder stehen Skleritis und Uveitis. Der vorliegende Artikel soll die Probleme, die bei möglicher Assoziation einer rheumatischen Erkrankung mit dem Auge entstehen, aufzeigen und helfen diese zu lösen. Die Krankheitsbezeichnung „Uveitis“ sollte nicht ausreichend sein für eine einzuleitende Diagnostik und Therapie, vielmehr sollte zumindest die Lokalisation, möglichst auch die Ätiologie vorliegen. Meist lässt sich diese durch eine genaue klinische Untersuchung, unterstützt durch eine gezielte Anamnese, finden. Nur selten sind okuläre Entzündung und rheumatologisches Krankheitsbild zeitlich assoziiert, was genauer am Beispiel der HLA-B27-assoziierten Uveitis und der mit der juvenilen idiopathischen Arthritis assoziierten Uveitis dargestellt wird. Wichtig ist es, dass bei ophthalmologischer Erkrankung auch die Therapie vom Ophthalmologen vorgeschlagen wird. Schließlich werden die Aufgaben des rheumatologisch arbeitenden Internisten genauer betrachtet.AbstractOcular findings can be very typical for general disorders associated with rheumatological diseases. Of these ocular diseases, scleritis and uveitis are of particular significance. The present article discusses and attempts to solve the problems which can be seen when ocular inflammation is associated with rheumatological disorders. The identification of “uveitis” should not be sufficient to initiate diagnosis and therapy, but rather its localisation and, where possible, also its etiology should be known. These can usually be found with good clinical investigation and careful patient history. Only rarely are ocular and rheumatological inflammation active at the same time, as will be discussed later using HLA-B27-associated uveitis and juvenile idiopathic arthritis-associated uveitis as examples. It is important in the case of ocular inflammation that the indication for treatment be made by an ophthalmologist. Finally, the role of the rheumatologist in the treatment of this patient group will be described in detail.Ocular findings can be very typical for general disorders associated with rheumatological diseases. Of these ocular diseases, scleritis and uveitis are of particular significance. The present article discusses and attempts to solve the problems which can be seen when ocular inflammation is associated with rheumatological disorders. The identification of uveitis should not be sufficient to initiate diagnosis and therapy, but rather its localisation and, where possible, also its etiology should be known. These can usually be found with good clinical investigation and careful patient history. Only rarely are ocular and rheumatological inflammation active at the same time, as will be discussed later using HLA-B27-associated uveitis and juvenile idiopathic arthritis-associated uveitis as examples. It is important in the case of ocular inflammation that the indication for treatment be made by an ophthalmologist. Finally, the role of the rheumatologist in the treatment of this patient group will be described in detail.

[Rheumatic diseases with primary onset in young adults: spondyloarthritis and connective tissue diseases].

ZusammenfassungEntzündlich-rheumatische Erkrankungen können in jedem Lebensalter auftreten. Erstmanifestationen im jungen Erwachsenenalter finden sich v.xa0a. bei den Spondyloarthritiden und beim systemischen Lupus erythematodes (SLE), der zur Gruppe der Kollagenosen gehört. Entzündlicher Rückenschmerz, HLA-B27, Veränderungen der Iliosakralfugen in der Bildgebung sowie extraartikuläre Manifestationen sollten vom primär aufgesuchten Hausarzt oder Internisten bedacht werden, damit Patienten mit einer vermuteten Spondyloarthritis frühzeitig einer fachärztlichen Betreuung zugeführt werden können. Gleiches gilt für die Haut- und Organmanifestationen, allen voran die Lupusnephritis, sowie das Autoantikörperscreening, insbesondere auf antinukleäre und Anti-dsDNA-Antikörper bei Verdacht auf einen SLE. Die Patienten stehen häufig am Beginn ihres Berufs- und Familienlebens. Nur bei rascher Diagnosestellung kann zeitnah eine adäquate Therapie eingeleitet werden, die längerfristige Einschränkungen verhindert bzw. minimiert.AbstractInflammatory rheumatic diseases can occur at any age. In young adulthood spondyloarthritis and systemic lupus erythematosus in particular present the first symptoms. General practitioners and internists are the first to be contacted by patients. They should be familiar with inflammatory back pain, HLA B27, inflammatory signs in the sacroiliac joints on imaging and extra-articular manifestations in order to transfer patients suspected of having spondyloarthritis to a rheumatologist. The same applies to skin and organ involvement, especially lupus nephritis, in patients with suspected systemic lupus erythematosus, as well as antibody screening in particular for antinuclear antibodies and anti-double stranded DNA (dsDNA) antibodies. Patients are often at the beginning of their professional and family career, therefore, early diagnosis is necessary to initiate an adequate therapy and prevent or minimize long-term damage.Inflammatory rheumatic diseases can occur at any age. In young adulthood spondyloarthritis and systemic lupus erythematosus in particular present the first symptoms. General practitioners and internists are the first to be contacted by patients. They should be familiar with inflammatory back pain, HLA B27, inflammatory signs in the sacroiliac joints on imaging and extra-articular manifestations in order to transfer patients suspected of having spondyloarthritis to a rheumatologist. The same applies to skin and organ involvement, especially lupus nephritis, in patients with suspected systemic lupus erythematosus, as well as antibody screening in particular for antinuclear antibodies and anti-double stranded DNA (dsDNA) antibodies. Patients are often at the beginning of their professional and family career, therefore, early diagnosis is necessary to initiate an adequate therapy and prevent or minimize long-term damage.

Probleme bei der Versorgung von Augenerkrankungen im Rahmen entzündlich rheumatischer Grunderkrankungen

ZusammenfassungAugenbefunde können wegweisend für rheumatologische Systemerkrankungen sein. Im Mittelpunkt dieser okulären Krankheitsbilder stehen Skleritis und Uveitis. Der vorliegende Artikel soll die Probleme, die bei möglicher Assoziation einer rheumatischen Erkrankung mit dem Auge entstehen, aufzeigen und helfen diese zu lösen. Die Krankheitsbezeichnung „Uveitis“ sollte nicht ausreichend sein für eine einzuleitende Diagnostik und Therapie, vielmehr sollte zumindest die Lokalisation, möglichst auch die Ätiologie vorliegen. Meist lässt sich diese durch eine genaue klinische Untersuchung, unterstützt durch eine gezielte Anamnese, finden. Nur selten sind okuläre Entzündung und rheumatologisches Krankheitsbild zeitlich assoziiert, was genauer am Beispiel der HLA-B27-assoziierten Uveitis und der mit der juvenilen idiopathischen Arthritis assoziierten Uveitis dargestellt wird. Wichtig ist es, dass bei ophthalmologischer Erkrankung auch die Therapie vom Ophthalmologen vorgeschlagen wird. Schließlich werden die Aufgaben des rheumatologisch arbeitenden Internisten genauer betrachtet.AbstractOcular findings can be very typical for general disorders associated with rheumatological diseases. Of these ocular diseases, scleritis and uveitis are of particular significance. The present article discusses and attempts to solve the problems which can be seen when ocular inflammation is associated with rheumatological disorders. The identification of “uveitis” should not be sufficient to initiate diagnosis and therapy, but rather its localisation and, where possible, also its etiology should be known. These can usually be found with good clinical investigation and careful patient history. Only rarely are ocular and rheumatological inflammation active at the same time, as will be discussed later using HLA-B27-associated uveitis and juvenile idiopathic arthritis-associated uveitis as examples. It is important in the case of ocular inflammation that the indication for treatment be made by an ophthalmologist. Finally, the role of the rheumatologist in the treatment of this patient group will be described in detail.Ocular findings can be very typical for general disorders associated with rheumatological diseases. Of these ocular diseases, scleritis and uveitis are of particular significance. The present article discusses and attempts to solve the problems which can be seen when ocular inflammation is associated with rheumatological disorders. The identification of uveitis should not be sufficient to initiate diagnosis and therapy, but rather its localisation and, where possible, also its etiology should be known. These can usually be found with good clinical investigation and careful patient history. Only rarely are ocular and rheumatological inflammation active at the same time, as will be discussed later using HLA-B27-associated uveitis and juvenile idiopathic arthritis-associated uveitis as examples. It is important in the case of ocular inflammation that the indication for treatment be made by an ophthalmologist. Finally, the role of the rheumatologist in the treatment of this patient group will be described in detail.

Was der Rheumatologe vom Augenarzt lernen kann

Intraocular inflammation with the imprecise and broad umbrella term uveitis is axa0diagnostic and therapeutic challenge in ophthalmology. Uveitis is one of the most common causes of blindness worldwide and due to the associated costs is comparable to diabetic retinopathy. Patients can be affected by uveitis at any age. Any part of the eye may be affected. The symptoms range from complete absence of symptoms, through all types of vision deterioration up to axa0red and even very painful eye. Uveitis can be strictly unilateral (also alternating from the left to the right eye) or bilateral with axa0relapsing or chronic course. The transitions are smooth and the differential diagnoses are very broad. In addition to infectious forms and ocular syndromes restricted to the eye, it also includes those with extraocular systemic diseases, such as ankylosing spondylitis or sarcoidosis. All commonly administered immunosuppressive treatment strategies in rheumatology can be used for non-infectious forms in addition to local and regional forms of treatment. The diagnostic and therapeutic impulses of this interdisciplinary interface between rheumatology and ophthalmology is discussed in more detail in this article.ZusammenfassungIntraokulare Entzündungen mit dem unpräzisen und weit gefassten Überbegriff „Uveitis“ stellen in der Ophthalmologie eine diagnostische und therapeutische Herausforderung dar. Uveitiden sind eine der häufigsten Erblindungsursachen weltweit. Die durch sie hervorgerufenen Kosten sind vergleichbar mit denen der diabetischen Retinopathie. Patienten können in jedem Alter von einer Uveitis betroffen werden. Alle Bereiche des Auges können befallen sein. Die Symptomatik reicht von völliger Beschwerdefreiheit, über alle Arten der Sehverschlechterung bis hin zum roten, ja sogar sehr schmerzhaften Auge. Eine Uveitis kann streng einseitig (auch links rechts wechselnd) oder beidseitig auftreten mit schubweisem oder chronischem Verlauf. Die Übergänge sind fließend, und die Differenzialdiagnose ist sehr breit. Sie beinhaltet neben infektiösen Formen und auf das Auge beschränkten okulären Syndromen auch solche mit extraokulären Systemerkrankungen wie der ankylosierenden Spondylitis oder der Sarkoidose. Alle üblichen immunsuppressiven Therapieformen der Rheumatologie können neben lokalen und regionalen Behandlungsarten bei den nichtinfektiösen Formen zum Einsatz kommen. Die diagnostischen und therapeutischen Impulse dieser interdisziplinären Schnittstelle zwischen Rheumatologie und Ophthalmologie sollen in diesem Beitrag näher beleuchtet werden.AbstractIntraocular inflammation with the imprecise and broad umbrella term “uveitis” is axa0diagnostic and therapeutic challenge in ophthalmology. Uveitis is one of the most common causes of blindness worldwide and due to the associated costs is comparable to diabetic retinopathy. Patients can be affected by uveitis at any age. Any part of the eye may be affected. The symptoms range from complete absence of symptoms, through all types of vision deterioration up to axa0red and even very painful eye. Uveitis can be strictly unilateral (also alternating from the left to the right eye) or bilateral with axa0relapsing or chronic course. The transitions are smooth and the differential diagnoses are very broad. In addition to infectious forms and ocular syndromes restricted to the eye, it also includes those with extraocular systemic diseases, such as ankylosing spondylitis or sarcoidosis. All commonly administered immunosuppressive treatment strategies in rheumatology can be used for non-infectious forms in addition to local and regional forms of treatment. The diagnostic and therapeutic impulses of this interdisciplinary interface between rheumatology and ophthalmology is discussed in more detail in this article.

FRI0098 Elevated multi-biomarker disease activity (MBDA) predicts relapses in ra patients in sustained remission tapering tumour necrosis factor inhibitor therapy- results from the randomized controlled retro study

Background Tumor necrosis factor inhibitors (TNFi) are the most frequently used bDMARDs in RA patients. TNFi induces remission in a substantial numbers of patients. Once remission, particularly sustained remission is achieved the question arises whether TNFi can be successfully tapered. To date biomarkers, which can help to predict if TNFi can be tapered or stopped, remain to be developed. Objectives To test whether residual subclinical inflammation assessed by multi-biomarker disease activity (MBDA) predicts the risk of disease relapse after tapering or stopping TNFi treatment in RA patients in sustained remission. Methods Sub-analysis of TNFi treated patients of the RETRO study, a randomized-controlled study in RA patients in sustained (>6 month) DAS28 remission comparing 3 different DMARD treatment strategies (continuation of full dose, 50% dose tapering, stopping after 50% dose tapering). Patients were followed over one year for the occurrence of relapses as defined by leaving DAS28-ESR remission (>2.6 units) (1). Vectra-DA tests were done in the baseline samples of all patients included into the RETRO study. MBDA score was calculated according to previously defined algorithms with low MDBA score defined as <30 units and moderate to high scores as ≥30 units (2). Results Of the 151 patients included in the RETRO study, 42 received TNFi treatment (mean age: 56 ys, 25 (60%) females, 78% concomitant csDMARDs; 69% ACPA/RF positive. Baseline demographic and disease specific characteristics of these patients were comparable to the non-TNFi treated patients of the RETRO study. 26/42 patients (62%) had low MBDA scores at baseline, while 16/42 (38%) had moderate/high scores. Relapse rates were significantly (chi square p=0.016) lower in RA patients with low MBDA scores (N=8 of 26; 31%) than in those with moderate/high scores (N=11 of 16; 69%) (Figure; left graph). When separately analyzing only patients tapering TNFi (N=29), relapse rates were moderate in RA patients with low MBDA scores (N=6 of 16; 37%) but high in those with moderate/high scores (N=10 of 13; 77%) (chi square p=0.015) (Figure; right graph). Conclusions These data show that the majority of RA patients in sustained clinical remission with low MBDA scores can successfully taper TNFi. In contrast tapering cannot be recommended in patients with moderate to high MBDA scores, as relapse rates are high in these patients. References Haschka J et al. Ann Rheum Dis 2016,75;45–51. Curtis JR et al. Arthritis Care Res 2012;64:1794–803. Disclosure of Interest None declared

AB0068 Hypoxia and rheumatoid phenotype decrease the capacity of synovial fibroblasts to suppress t helper cell proliferation through ido1-mediated tryptophan catabolism

Background The pathogenesis of rheumatoid arthritis (RA) is linked to functional changes in synovial fibroblasts (SF) and local infiltration of T lymphocytes. Increased synovial inflammation is also associated with a hypoxic joint microenvironment. Oxygen levels in the joints of RA patients are significantly decreased compared to those of osteoarthritis (OA) patients with values of about 22.5mmHg corresponding to ambient oxygen tensions of 3.2%. So far, little is known about the effects of hypoxia on the interaction between fibroblasts and T lymphocytes and its implications on the pathophysiology of RA. Objectives The aim of this study was to compare the influence of SF from RA versus OA patients on T helper (Th) cell responses both under normoxic and hypoxic conditions. Methods SF were isolated from synovectomy tissues of OA or RA patients, Th cells were isolated from peripheral blood of RA patients or healthy donors. Cell cultures were performed under normoxic or hypoxic (3% O2) conditions. Th cell proliferation was determined by PKH26 labelling and flow cytometry. Cytokine secretion was quantified by ELISA. Indoleamine 2,3-dioxygenase 1 (IDO1) expression was analysed by Western Blot and expression of enzymes of the kynurenine pathway by real-time PCR. Tryptophan/ kynurenine levels in culture supernatants were quantified by HPLC. Results SF strongly inhibited the proliferation of co-cultured Th cells. Tryptophan was completely depleted within a few days in co-cultures of SF and Th cells, resulting in eukaryotic initiation factor (eIF)2α phosphorylation, TCRζ-chain down-regulation and proliferation arrest. Blocking of IDO1 completely restored Th cell proliferation, indicating that SF suppressed the proliferation of Th cells through IDO1-mediated tryptophan catabolism. Interestingly, RASF showed a significantly lower IDO1 expression, tryptophan metabolism and a weaker Th cell suppressive capacity compared to OASF. Under hypoxic conditions, the secretion of IFNg, the expression of IDO1, the tryptophan metabolism and the Th cell suppressive capacity of both OASF and RASF were significantly reduced. Conclusions SF suppressed Th cell growth through IDO1-mediated tryptophan catabolism. This mechanism may play an important role in preventing inappropriate Th cell responses under normal conditions. The reduced tryptophan metabolism under hypoxia together with the inferior efficiency of RASF to restrict T cell proliferation likely supports the development of synovitis in RA. Disclosure of Interest None declared